Provider Demographics
NPI:1053950907
Name:JOHNSON, JACKIENEL
Entity type:Individual
Prefix:MRS
First Name:JACKIENEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16105 CHENAL PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4824
Mailing Address - Country:US
Mailing Address - Phone:501-217-7920
Mailing Address - Fax:501-217-7922
Practice Address - Street 1:16105 CHENAL PKWY STE B
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4824
Practice Address - Country:US
Practice Address - Phone:501-217-7920
Practice Address - Fax:501-217-7922
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR77341835P0018X, 183500000X
AR077341835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist