Provider Demographics
NPI:1619403615
Name:JACKSON, THOMAS M (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD, MSD
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 327
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0327
Mailing Address - Country:US
Mailing Address - Phone:870-886-7992
Mailing Address - Fax:
Practice Address - Street 1:2737 PAULA DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8017
Practice Address - Country:US
Practice Address - Phone:901-932-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR391223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty