Provider Demographics
NPI:1710081823
Name:JACKSON, PATRICIA ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3725
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-3725
Mailing Address - Country:US
Mailing Address - Phone:870-793-3210
Mailing Address - Fax:
Practice Address - Street 1:225 3RD ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501
Practice Address - Country:US
Practice Address - Phone:870-793-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T69482Medicare UPIN
AR59443Medicare ID - Type Unspecified