Basic Information
| Provider Information | |||||||||
| NPI: | 1346211273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DARRYE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 N 9TH ST | ||||||||
| Address2: | PO BOX 497 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472543 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 EAST COURT STREET | ||||||||
| Address2: | KENTUCKYCARE | ||||||||
| City: | BARDWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420238483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706283333 | ||||||||
| FaxNumber: | 2706283334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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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 | 363LF0000X | 3315P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 78005923 | 05 | KY | MEDICAID |