Provider Demographics
NPI:1376175521
Name:BLACKMON, JAMES EDWIN (LPC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWIN
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 TIMBER CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5871
Mailing Address - Country:US
Mailing Address - Phone:662-801-0271
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST STE 2C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4017
Practice Address - Country:US
Practice Address - Phone:662-760-0052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional