Provider Demographics
NPI:1083448898
Name:HAWKINS, JACKIE HAKEEM
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:HAKEEM
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 RICHMOND RD # 209
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2406
Mailing Address - Country:US
Mailing Address - Phone:430-274-4671
Mailing Address - Fax:
Practice Address - Street 1:700 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4416
Practice Address - Country:US
Practice Address - Phone:870-864-3390
Practice Address - Fax:870-864-2152
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR230133367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered