Provider Demographics
NPI:1215574561
Name:BLACKWELL, JACK (RADT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W BEAMER ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2510
Mailing Address - Country:US
Mailing Address - Phone:530-405-2815
Mailing Address - Fax:
Practice Address - Street 1:215 W BEAMER ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2510
Practice Address - Country:US
Practice Address - Phone:530-405-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)