Provider Demographics
NPI:1386935260
Name:JACKSON, CHRISSY (QBHP)
Entity type:Individual
Prefix:
First Name:CHRISSY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:CHRISSY
Other - Middle Name:
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2885 W BATTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 W ELM ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4018
Practice Address - Country:US
Practice Address - Phone:479-636-0083
Practice Address - Fax:479-636-0144
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231304795Medicaid