Provider Demographics
NPI:1902292329
Name:JACKSON, KIM NGAN THI (MD)
Entity Type:Individual
Prefix:
First Name:KIM NGAN
Middle Name:THI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 CORPORATE HILL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4565
Mailing Address - Country:US
Mailing Address - Phone:501-978-7113
Mailing Address - Fax:
Practice Address - Street 1:18 CORPORATE HILL DR STE 110
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4565
Practice Address - Country:US
Practice Address - Phone:501-224-1156
Practice Address - Fax:501-223-2625
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE13055207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Single Specialty