Individual
DR. EDWARD LESLIE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3344 N FUTRALL DR, FAYETTEVILLE, AR 72703-4057
(479) 521-8200
(479) 582-7310
Mailing address
PO BOX 1523, FAYETTEVILLE, AR 72702-1523
(479) 521-8200
(479) 582-7310
Taxonomy
Speciality
Code
Description
License number
State
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
E-4775
AR
207RP1001X
Pulmonary Disease Physician
Primary
E-4775
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
160768001
—
AR
05
—
200088310A
—
OK
01
—
5N545
AR BCBS
AR
01
—
P00327943
RR MCR
AR
Enumeration date
11/21/2005
Last updated
03/14/2024
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