Provider Demographics
NPI:1013544774
Name:BLACKWELL, JEFFREY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:12180 ALDER ST
Practice Address - Street 2:
Practice Address - City:MEADOWVIEW
Practice Address - State:VA
Practice Address - Zip Code:24361
Practice Address - Country:US
Practice Address - Phone:276-695-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program