Provider Demographics
NPI:1780660159
Name:JACKSON, STRACY (CNA)
Entity Type:Individual
Prefix:
First Name:STRACY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-2105
Mailing Address - Country:US
Mailing Address - Phone:870-222-3587
Mailing Address - Fax:
Practice Address - Street 1:901 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2563
Practice Address - Country:US
Practice Address - Phone:870-222-3805
Practice Address - Fax:870-222-3984
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR050024070304E374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide