Basic Information
| Provider Information | |||||||||
| NPI: | 1538195524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | PRESLEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012215850 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 LILE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012278000 | ||||||||
| FaxNumber: | 5012215850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 09/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R2633 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104704001 | 05 | AR | MEDICAID |