Provider Demographics
NPI:1366320897
Name:JACKSON, FAWN (RPH)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 HASLEY RD
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-8858
Mailing Address - Country:US
Mailing Address - Phone:501-297-0091
Mailing Address - Fax:
Practice Address - Street 1:102 N 27TH ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4233
Practice Address - Country:US
Practice Address - Phone:870-464-9560
Practice Address - Fax:870-464-9561
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD17450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist