1619103702 NPI number — MR. JOEY MATTHEW JACKSON LCSW

Table of content: MR. JOEY MATTHEW JACKSON LCSW (NPI 1619103702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619103702 NPI number — MR. JOEY MATTHEW JACKSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JOEY
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
JOEY
Provider Other Middle Name:
MATTHEW
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619103702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-7870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-6886
Provider Business Mailing Address Fax Number:
870-933-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 MORGAN ST
Provider Second Line Business Practice Location Address:
STE 8
Provider Business Practice Location Address City Name:
PARAGOULD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72450-3949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-355-9483
Provider Business Practice Location Address Fax Number:
870-335-9487
Provider Enumeration Date:
06/03/2009

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: 1041C0700X , with the licence number:  9607-C , 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)