Provider Demographics
NPI:1144291907
Name:JACKSON, KEVIN T (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 HIGHWAY 62 65 N
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-1959
Mailing Address - Country:US
Mailing Address - Phone:479-741-3600
Mailing Address - Fax:870-741-4482
Practice Address - Street 1:1420 HIGHWAY 62 65 N
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1959
Practice Address - Country:US
Practice Address - Phone:479-741-3600
Practice Address - Fax:870-741-4482
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARH27518Medicare UPIN
AR142279001Medicare ID - Type Unspecified
ARH27518Medicare UPIN