Provider Demographics
NPI:1710320320
Name:JACKSON, DEBRA A
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS WAY
Mailing Address - Street 2:SLOT 512-39
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-526-8700
Mailing Address - Fax:501-526-8740
Practice Address - Street 1:3450 W 34TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5508
Practice Address - Country:US
Practice Address - Phone:870-534-6067
Practice Address - Fax:870-534-7297
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL030099164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse