Provider Demographics
NPI:1801866900
Name:JACKSON, JABEZ FENTON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JABEZ
Middle Name:FENTON
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-1210
Mailing Address - Country:US
Mailing Address - Phone:870-523-5713
Mailing Address - Fax:870-523-4846
Practice Address - Street 1:1201 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3533
Practice Address - Country:US
Practice Address - Phone:870-523-3289
Practice Address - Fax:870-523-4846
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC4208207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102814001Medicaid
AR52600Medicare PIN
ARC68569Medicare UPIN