Provider Demographics
NPI:1679162945
Name:JACKSON, JOYCE
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:JACKSON
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 1:607 HIGHWAY 71 E STE B
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:AR
Mailing Address - Zip Code:72944-3709
Mailing Address - Country:US
Mailing Address - Phone:479-269-6161
Mailing Address - Fax:
Practice Address - Street 1:607 HIGHWAY 71 E STE B
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:AR
Practice Address - Zip Code:72944-3709
Practice Address - Country:US
Practice Address - Phone:479-269-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07742183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist