Provider Demographics
NPI:1033754767
Name:BLACKWELL, JILLIAN LEAH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEAH
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 S LAMAR BLVD STE 550
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2988
Mailing Address - Country:US
Mailing Address - Phone:512-442-6777
Mailing Address - Fax:
Practice Address - Street 1:1509 S LAMAR BLVD STE 550
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2988
Practice Address - Country:US
Practice Address - Phone:512-442-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist