Provider Demographics
NPI:1083689855
Name:JACKSON, MATTHEW PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PATRICK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403
Mailing Address - Country:US
Mailing Address - Phone:870-523-9337
Mailing Address - Fax:870-217-0312
Practice Address - Street 1:1500 MCLAIN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3638
Practice Address - Country:US
Practice Address - Phone:870-523-9337
Practice Address - Fax:870-217-0312
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2332207Q00000X
ARE-2332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138695001Medicaid
AR5L338OtherMEDICARE PROVIDER NUMBER
5L338Medicare PIN
H03268Medicare UPIN
ARH03268Medicare UPIN