Active NPI
Janissa D Jackson, PHD
- Clinical Child & Adolescent Psychologist
- Fort Smith, AR
National Provider Identifier
1043365620
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Child & Adolescent Psychologist
- License
- 07-01P
- Practice address
- 5401 Rogers Ave Ste 201
Fort Smith, AR 72903-3763 - Phone
- (479) 242-4560
- Fax
- (479) 242-4561
- NPI assigned
- Jan 24, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 07-01P | AR | |
| Clinical Child & Adolescent Psychologist | 103TC2200X | 07-01P | AR | Primary |
Addresses
Primary practice location
5401 Rogers Ave Ste 201
Fort Smith, AR 72903-3763
Mailing address
5401 Rogers Ave Ste 201
Fort Smith, AR 72903-3763
Phone (479) 242-4560
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5A252 | Other | AR | BLUECROSS BLUESHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 07-01P | AR | MD | Clinical Child & Adolescent Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Janissa D Jackson PHD PLLC | Clinical | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Clinical Child & Adolescent Psychologist
- Fayetteville, AR
- NPI 1871762476
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1169596800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1729123200000",
"number": "1043365620",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5401 ROGERS AVE STE 201",
"city": "FORT SMITH",
"state": "AR",
"postal_code": "729033763",
"telephone_number": "479-242-4560",
"fax_number": "479-242-4561"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5401 ROGERS AVE STE 201",
"city": "FORT SMITH",
"state": "AR",
"postal_code": "729033763",
"telephone_number": "479-242-4560",
"fax_number": "479-242-4561"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JANISSA",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-01-24",
"last_updated": "2024-10-17",
"certification_date": "2024-10-17",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "AR",
"license": "07-01P",
"primary": false
},
{
"code": "103TC2200X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical Child & Adolescent",
"state": "AR",
"license": "07-01P",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUECROSS BLUESHIELD",
"identifier": "5A252",
"state": "AR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Smith, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.