1053372946 NPI number — DR. MARTHA A JACKSON DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053372946 NPI number — DR. MARTHA A JACKSON DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARTHA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053372946
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2501 CRESTWOOD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72116-7615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-771-4785
Provider Business Mailing Address Fax Number:
501-771-4787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 CRESTWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72116-7615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-771-4785
Provider Business Practice Location Address Fax Number:
501-771-4787
Provider Enumeration Date:
03/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  87 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16253000040 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5997156 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0580220001 . This is a "PALMETTO DME" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9468520001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2720028 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 56243 . This is a "FEP BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56243 . This is a "FIRST SOURCE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56243 . This is a "AR BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56243 . This is a "HEALTH ADVANTAGE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 110420717 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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