| Doctor Name: | AUDRA M JACKSON |
| NPI Number: | 1093815268 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MD |
| License Number: | |
| Business Practice Address: | 3808 South Gary Fort Smith, AR - 729035450 |
| Business Phone Number: | 4797097120 |
| Business Fax Number: | 4797097123 |
| Mailing Address: | Po Box 402319, ATLANTA |
| State: | GA |
| Postal Code: | 303842319 |
| Phone Number: | 4797097399 |
| Fax Number: | 4797097053 |
| NPI Enumeration Date: | 09/25/2006 |
| NPI Last Update Date: | 08/23/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |