Provider Demographics
NPI:1679699607
Name:JACKSON, NEALL CLARK (DDS)
Entity type:Individual
Prefix:DR
First Name:NEALL
Middle Name:CLARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 EAST ELDRIDGE AVENUE
Mailing Address - Street 2:P.O. BOX 368
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0368
Mailing Address - Country:US
Mailing Address - Phone:870-238-3628
Mailing Address - Fax:870-238-0757
Practice Address - Street 1:715 EAST ELDRIDGE AVENUE
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-0368
Practice Address - Country:US
Practice Address - Phone:870-238-3628
Practice Address - Fax:870-238-0757
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist