Provider Demographics
NPI:1043094105
Name:JACKSON, FAITH
Entity type:Individual
Prefix:
First Name:FAITH
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 1:221 LINDLEY LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-4954
Mailing Address - Country:US
Mailing Address - Phone:870-523-2124
Mailing Address - Fax:
Practice Address - Street 1:221 LINDLEY LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-4954
Practice Address - Country:US
Practice Address - Phone:870-523-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist