Healthcare Provider Details

I. General information

NPI: 1841245883
Provider Name (Legal Business Name): JACK R CHILDRESS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SEQUOYA DR
LAKE KIOWA TX
76240-9446
US

IV. Provider business mailing address

105 SEQUOYA DR
LAKE KIOWA TX
76240-9446
US

V. Phone/Fax

Practice location:
  • Phone: 940-736-8885
  • Fax: 940-668-8292
Mailing address:
  • Phone: 940-736-8885
  • Fax: 940-668-8292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number346502
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14502A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number97208
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberH5535
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH5535
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: