Provider Demographics
NPI:1518400183
Name:BLACKMAN, JENNY T (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:T
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3052 WILLOW PASS RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-2552
Mailing Address - Country:US
Mailing Address - Phone:925-681-4145
Mailing Address - Fax:
Practice Address - Street 1:3052 WILLOW PASS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2552
Practice Address - Country:US
Practice Address - Phone:925-681-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95005299363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care