Individual
JACK R CHILDRESS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
105 SEQUOYA DR, LAKE KIOWA, TX 76240-9446
(940) 736-8885
(940) 668-8292
Mailing address
105 SEQUOYA DR, LAKE KIOWA, TX 76240-9446
(940) 736-8885
(940) 668-8292
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
14502A
WY
207R00000X
Internal Medicine Physician
346502
LA
207R00000X
Internal Medicine Physician
97208
GA
207R00000X
Internal Medicine Physician
Primary
H5535
TX
208M00000X
Hospitalist Physician
H5535
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1140766-07
—
TX
05
—
163713001
—
AR
01
—
84487
BCBS-ARKANSAS
AR
01
—
8V4246
BCBS-TEXAS
TX
01
—
P00466537
RR MEDICARE
TX
Enumeration date
05/24/2006
Last updated
06/03/2025
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