Provider Demographics
NPI:1891480273
Name:JACKSON, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WILLOW CREEK LN APT 4302
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7991
Mailing Address - Country:US
Mailing Address - Phone:954-464-8137
Mailing Address - Fax:
Practice Address - Street 1:300 CARSON ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3104
Practice Address - Country:US
Practice Address - Phone:709-321-1988
Practice Address - Fax:870-910-7700
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program