Provider Demographics
NPI:1033764485
Name:BLACKMON, JUANITA (MS)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 S KEDZIE AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-3216
Mailing Address - Country:US
Mailing Address - Phone:312-342-9118
Mailing Address - Fax:
Practice Address - Street 1:5904 S KEDZIE AVE APT 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-3216
Practice Address - Country:US
Practice Address - Phone:312-342-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist