Provider Demographics
NPI:1861215840
Name:JACKSON, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13364 HIGHWAY 219
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-8939
Mailing Address - Country:US
Mailing Address - Phone:479-209-2545
Mailing Address - Fax:
Practice Address - Street 1:2120 S WALDRON RD STE C
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3689
Practice Address - Country:US
Practice Address - Phone:479-452-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2294225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner