Provider Demographics
NPI:1629258595
Name:JACKSONVILLE CHIROPRACTIC P. A.
Entity Type:Organization
Organization Name:JACKSONVILLE CHIROPRACTIC P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-985-7711
Mailing Address - Street 1:1727 T P WHITE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-2861
Mailing Address - Country:US
Mailing Address - Phone:501-985-7711
Mailing Address - Fax:501-985-8385
Practice Address - Street 1:1727 T P WHITE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-2861
Practice Address - Country:US
Practice Address - Phone:501-985-7711
Practice Address - Fax:501-985-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T401OtherMEDICARE GROUP MEMBER PTAN
AR5F994OtherMEDICARE GROUP PTAN
ARU63233OtherUPIN