Provider Demographics
NPI:1952302457
Name:JACKSON, HAYNES G JR (MD)
Entity Type:Individual
Prefix:
First Name:HAYNES
Middle Name:G
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
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 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:501-627-1800
Mailing Address - Fax:501-627-1899
Practice Address - Street 1:118 WOMENS CENTER LANE
Practice Address - Street 2:SUITE B
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-321-2229
Practice Address - Fax:501-609-2342
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4886207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104689001Medicaid
F01074Medicare UPIN
AR52599Medicare ID - Type Unspecified