Provider Demographics
NPI:1063790079
Name:JACKS, DENNIS WILLIAM (CRNA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:WILLIAM
Last Name:JACKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 MIDTOWN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5313
Mailing Address - Country:US
Mailing Address - Phone:501-664-4532
Mailing Address - Fax:501-663-4335
Practice Address - Street 1:6119 MIDTOWN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5313
Practice Address - Country:US
Practice Address - Phone:501-664-4532
Practice Address - Fax:501-663-4335
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC002870367500000X
ARR070488163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4A100C752Medicare PIN