Provider Demographics
NPI:1346860442
Name:BLACKBURN, JUSTIN RYAN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RYAN
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 GALLIA ST STE A
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5563
Mailing Address - Country:US
Mailing Address - Phone:740-529-1184
Mailing Address - Fax:740-876-4118
Practice Address - Street 1:4342 GALLIA ST STE A
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:OH
Practice Address - Zip Code:45662-5563
Practice Address - Country:US
Practice Address - Phone:740-529-1184
Practice Address - Fax:740-876-4118
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator