Basic Information
| Provider Information | |||||||||
| NPI: | 1760781439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JAMEELA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 HIGHWAY 67 BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720158909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018215500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6701 HIGHWAY 67 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720158909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013033105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | A1510138 | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | P1808113 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.