Provider Demographics
NPI:1053372946
Name:JACKSON, MARTHA A (DPM)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2501 CRESTWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7615
Mailing Address - Country:US
Mailing Address - Phone:501-771-4785
Mailing Address - Fax:501-771-4787
Practice Address - Street 1:2501 CRESTWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7615
Practice Address - Country:US
Practice Address - Phone:501-771-4785
Practice Address - Fax:501-771-4787
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR87213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR16253000040OtherQUAL CHOICE
5997156OtherAETNA
0580220001OtherPALMETTO DME
9468520001OtherCIGNA
2720028OtherUNITED HEALTH CARE
AR56243OtherFEP BCBS
AR56243OtherFIRST SOURCE
AR56243OtherAR BCBS
AR56243OtherHEALTH ADVANTAGE
AR110420717Medicaid
9468520001OtherCIGNA
2720028OtherUNITED HEALTH CARE
48002815Medicare ID - Type UnspecifiedRAILROAD