Provider Demographics
NPI:1922038975
Name:BLAYLOCK, JERRY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:D
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4105
Mailing Address - Country:US
Mailing Address - Phone:870-935-0360
Mailing Address - Fax:870-972-8603
Practice Address - Street 1:901 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4105
Practice Address - Country:US
Practice Address - Phone:870-935-0360
Practice Address - Fax:870-972-8603
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4264101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101644001Medicaid
AR50529Medicare PIN
AR101644001Medicaid