Provider Demographics
NPI:1710694971
Name:JACKSON, CARLA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
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 7395
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-7395
Mailing Address - Country:US
Mailing Address - Phone:903-244-5368
Mailing Address - Fax:
Practice Address - Street 1:4903 HIGHWAY 67 W
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:AR
Practice Address - Zip Code:71838-9033
Practice Address - Country:US
Practice Address - Phone:903-244-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1036336261QI0500X, 261QP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care