Provider Demographics
NPI:1699948901
Name:JACKS, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JACKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603
Mailing Address - Country:US
Mailing Address - Phone:870-534-7546
Mailing Address - Fax:
Practice Address - Street 1:1718 W 42ND AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7008
Practice Address - Country:US
Practice Address - Phone:870-534-7546
Practice Address - Fax:870-534-2343
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7442207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology