# JANISSA D JACKSON PHD PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Janissa D Jackson PHD
- **Organization subpart:** No

## Provider details

- **NPI number:** 1871762476
- **Authorized official:** LAVONNA LATTA (BUSINESS MANAGER)
- **Authorized official phone:** (479) 443-5575

## Contact information

- **Practice address:** 1 W SUNBRIDGE DR, FAYETTEVILLE, AR 72703-1825
- **Practice address phone:** (479) 443-5575
- **Practice address fax:** (479) 443-9554
- **Mailing address:** 1 W SUNBRIDGE DR, FAYETTEVILLE, AR 72703-1825
- **Mailing address phone:** (479) 443-5575
- **Mailing address fax:** (479) 443-9554

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103TC0700X | Clinical Psychologist | 07-01P | AR | — |
| 103TC2200X | Clinical Child & Adolescent Psychologist | 07-01P | AR | Yes |

## Other

- **Enumeration date:** 02/27/2008
- **Last updated:** 02/27/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 5A252 | BLUECROSS BLUESHIELD | AR |