Provider Demographics
NPI:1124690680
Name:JACKSON, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S DODSON RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-5112
Mailing Address - Country:US
Mailing Address - Phone:318-550-7258
Mailing Address - Fax:
Practice Address - Street 1:3500 SE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5182
Practice Address - Country:US
Practice Address - Phone:479-621-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist