Provider Demographics
NPI:1437273570
Name:BLACKBURN, JACK ARCHER (LMP)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ARCHER
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5762 27TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5512
Mailing Address - Country:US
Mailing Address - Phone:206-527-0908
Mailing Address - Fax:
Practice Address - Street 1:5762 27TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5512
Practice Address - Country:US
Practice Address - Phone:206-527-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA242-01-0003420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist