1285968776 NPI number — NEALL JACKSON DDS PA

Table of content: (NPI 1285968776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285968776 NPI number — NEALL JACKSON DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEALL JACKSON DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PURYEAR JACKSON FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1285968776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 368
Provider Second Line Business Mailing Address:
715 EAST ELDRIDGE AVENUE
Provider Business Mailing Address City Name:
WYNNE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-238-3628
Provider Business Mailing Address Fax Number:
870-238-0757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 ELDRIDGE AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYNNE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72396-4032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-238-3628
Provider Business Practice Location Address Fax Number:
870-238-0757
Provider Enumeration Date:
09/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CATHEY
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
DIANE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
870-238-3628

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3520 , 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: 159065608 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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