Provider Demographics
NPI:1205411766
Name:BLACKMON, JEAN D (RN)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:D
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 BEN SAWYER BLVD UNIT 5G
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5508
Mailing Address - Country:US
Mailing Address - Phone:843-367-9938
Mailing Address - Fax:
Practice Address - Street 1:1551 BEN SAWYER BLVD UNIT 5G
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5508
Practice Address - Country:US
Practice Address - Phone:843-367-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104325163WU0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WU0100XNursing Service ProvidersRegistered NurseUrology