Provider Demographics
NPI:1336267509
Name:JACKSON, SCOTT M (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:JACKSON
Suffix:
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 1:4375 N VANTAGE DR STE 305
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4984
Mailing Address - Country:US
Mailing Address - Phone:479-443-5100
Mailing Address - Fax:
Practice Address - Street 1:4375 N VANTAGE DR STE 305
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4984
Practice Address - Country:US
Practice Address - Phone:479-273-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE13748207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR261960001Medicaid
LA1057860Medicaid