Provider Demographics
NPI:1134803844
Name:BLAYLOCK, JACLYN B (CRNA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:B
Last Name:BLAYLOCK
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:RAE
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1 CHILDRENS WAY # 203
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-3933
Practice Address - Fax:501-364-2939
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR224922367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered