Provider Demographics
NPI:1679396329
Name:JACKSON, ANNA GENEVA (QBHP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:GENEVA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:GENEVA
Other - Last Name:WHITFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0717
Mailing Address - Country:US
Mailing Address - Phone:870-570-0358
Mailing Address - Fax:870-570-0359
Practice Address - Street 1:920 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-8416
Practice Address - Country:US
Practice Address - Phone:870-570-0358
Practice Address - Fax:870-570-0358
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator