Provider Demographics
NPI:1255726956
Name:JACKS, BLAKE BRICKEY (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:BRICKEY
Last Name:JACKS
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:PO BOX 55050
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5050
Mailing Address - Country:US
Mailing Address - Phone:501-906-0000
Mailing Address - Fax:501-907-6522
Practice Address - Street 1:8901 CARTI WAY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6523
Practice Address - Country:US
Practice Address - Phone:501-906-3000
Practice Address - Fax:501-907-6522
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-127302085R0202X, 2085R0204X
FLME1426752085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program