Active NPI
Charles David Jackson, MD
- Pediatrics Physician
- Fayetteville, AR
National Provider Identifier
1508800665
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- C-6427
- Practice address
- 3380 N Futrall Dr Ste 1
Fayetteville, AR 72703 - Phone
- (479) 442-7322
- Fax
- (479) 442-7379
- NPI assigned
- Jun 16, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | C-6427 | AR | Primary |
Addresses
Primary practice location
3380 N Futrall Dr Ste 1
Fayetteville, AR 72703
Mailing address
PO Box 1523
Fayetteville, AR 72702-1523
Phone (479) 571-6038
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 51110 | Other | AR | AR BC/BS |
| 113041001 | Medicaid | AR |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | charles.jackson@mana.eclinicaldirectplus.com | Direct |
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)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150416000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1640736000000",
"number": "1508800665",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1523",
"city": "FAYETTEVILLE",
"state": "AR",
"postal_code": "727021523",
"telephone_number": "479-571-6038",
"fax_number": "479-582-0222"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3380 N FUTRALL DR STE 1",
"city": "FAYETTEVILLE",
"state": "AR",
"postal_code": "72703",
"telephone_number": "479-442-7322",
"fax_number": "479-442-7379"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "CHARLES",
"middle_name": "DAVID",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-06-16",
"last_updated": "2021-12-29",
"certification_date": "2021-12-29",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "AR",
"license": "C-6427",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AR BC/BS",
"identifier": "51110",
"state": "AR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "113041001",
"state": "AR"
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "charles.jackson@mana.eclinicaldirectplus.com",
"affiliation": "N",
"endpointDescription": "charles.jackson@mana.eclinicaldirectplus.com",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "OTHER",
"contentTypeDescription": "Other",
"contentOtherDescription": "CCDA",
"address_1": "3380 N Futrall Dr Ste 1",
"city": "Fayetteville",
"state": "AR",
"country_code": "US",
"postal_code": "72703",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Fayetteville, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.