Provider Demographics
NPI:1073875902
Name:BLALOCK, JAMIE RIVKIN (MS, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RIVKIN
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:MS, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EARNEST DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8627
Mailing Address - Country:US
Mailing Address - Phone:706-745-8790
Mailing Address - Fax:
Practice Address - Street 1:15 EARNEST DR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8627
Practice Address - Country:US
Practice Address - Phone:706-745-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149435363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128313FMedicaid