Organization
JANISSA D JACKSON PHD PLLC
Active
Other names
Janissa D Jackson PHD
Organization subpart
No
Provider details
NPI number
Authorized official
LAVONNA LATTA (BUSINESS MANAGER)
(479) 443-5575
Entity
Organization
Contact information
Practice address
1 W SUNBRIDGE DR, FAYETTEVILLE, AR 72703-1825
(479) 443-5575
(479) 443-9554
Mailing address
1 W SUNBRIDGE DR, FAYETTEVILLE, AR 72703-1825
(479) 443-5575
(479) 443-9554
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
07-01P
AR
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
07-01P
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5A252
BLUECROSS BLUESHIELD
AR
Enumeration date
02/27/2008
Last updated
02/27/2008
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