Provider Demographics
NPI:1841245883
Name:CHILDRESS, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SEQUOYA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE KIOWA
Mailing Address - State:TX
Mailing Address - Zip Code:76240-9446
Mailing Address - Country:US
Mailing Address - Phone:940-736-8885
Mailing Address - Fax:940-668-8292
Practice Address - Street 1:105 SEQUOYA DR
Practice Address - Street 2:
Practice Address - City:LAKE KIOWA
Practice Address - State:TX
Practice Address - Zip Code:76240-9446
Practice Address - Country:US
Practice Address - Phone:940-736-8885
Practice Address - Fax:940-668-8292
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5535208M00000X, 207R00000X
WY14502A207R00000X
GA97208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V4246OtherBCBS-TEXAS
AR163713001Medicaid
TX1140766-07Medicaid
AR84487OtherBCBS-ARKANSAS
TXP00466537OtherRR MEDICARE
AR84487OtherBCBS-ARKANSAS
TX1140766-07Medicaid
TXP00466537Medicare PIN