Provider Demographics
NPI:1174852016
Name:BLACKWOOD, JERAMY DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JERAMY
Middle Name:DAVID
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-2939
Mailing Address - Country:US
Mailing Address - Phone:309-786-4131
Mailing Address - Fax:309-786-0797
Practice Address - Street 1:1929 10TH AVE E
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:IL
Practice Address - Zip Code:61264-2953
Practice Address - Country:US
Practice Address - Phone:309-787-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor