Basic Information
| Provider Information | |||||||||
| NPI: | 1093815268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402319 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097399 | ||||||||
| FaxNumber: | 4797097053 | ||||||||
| Practice Location | |||||||||
| Address1: | 3808 SOUTH GARY | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729035450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097120 | ||||||||
| FaxNumber: | 4797097123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E6098 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 200231990A | 05 | OK | MEDICAID |