Provider Demographics
NPI:1275086407
Name:BLACKWOOD, JAMIE LAWSON (CPNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LAWSON
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1855
Mailing Address - Country:US
Mailing Address - Phone:413-562-8330
Mailing Address - Fax:413-562-3430
Practice Address - Street 1:65 SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1855
Practice Address - Country:US
Practice Address - Phone:413-562-8330
Practice Address - Fax:413-562-3430
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203633363LP0200X
MARN2325703363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110150352AMedicaid