Provider Demographics
NPI:1770234775
Name:JACKSON, MEKEICHA L (DT)
Entity Type:Individual
Prefix:
First Name:MEKEICHA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 HARPENDEN CV
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-5334
Mailing Address - Country:US
Mailing Address - Phone:501-944-4584
Mailing Address - Fax:
Practice Address - Street 1:13800 HARPENDEN CV
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-5334
Practice Address - Country:US
Practice Address - Phone:501-944-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist