NPIMap

Organization Active NPI

Janissa D Jackson PHD PLLC

Doing business as Janissa D Jackson PHD

  • Clinical Child & Adolescent Psychologist
  • Fayetteville, AR
National Provider Identifier
1871762476
Registry record updated Feb 27, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X
License
07-01P Issued in AR
Legal business name
JANISSA D JACKSON PHD PLLC
Doing business as
Janissa D Jackson PHD
Practice address
1 W Sunbridge Dr
Fayetteville, AR 72703-1825
Phone
(479) 443-5575
Fax
(479) 443-9554
NPI assigned
Feb 27, 2008
Last updated
Feb 27, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 27, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lavonna Latta
Title
Business Manager
Phone
(479) 443-5575

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 07-01P AR
Clinical Child & Adolescent Psychologist 103TC2200X 07-01P AR Primary

Addresses

Primary practice location

1 W Sunbridge Dr
Fayetteville, AR 72703-1825

Mailing address

1 W Sunbridge Dr
Fayetteville, AR 72703-1825
Phone (479) 443-5575

Other identifiers 1

IdentifierTypeStateIssuer
5A252OtherARBLUECROSS BLUESHIELD

Other names 1

  • Janissa D Jackson PHD Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1204070400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1204070400000",
    "number": "1871762476",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 W SUNBRIDGE DR",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727031825",
            "telephone_number": "479-443-5575",
            "fax_number": "479-443-9554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 W SUNBRIDGE DR",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727031825",
            "telephone_number": "479-443-5575",
            "fax_number": "479-443-9554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JANISSA D JACKSON PHD PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-27",
        "last_updated": "2008-02-27",
        "status": "A",
        "authorized_official_last_name": "LATTA",
        "authorized_official_first_name": "LAVONNA",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "479-443-5575"
    },
    "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": [
        {
            "organization_name": "Janissa D Jackson PHD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Feb 27, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.