Provider Demographics
NPI:1467027896
Name:BLACKBURN, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 HICONE RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-9429
Mailing Address - Country:US
Mailing Address - Phone:336-529-9816
Mailing Address - Fax:
Practice Address - Street 1:1130 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1038
Practice Address - Country:US
Practice Address - Phone:336-375-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer