Provider Demographics
NPI:1538678503
Name:BLACKBURN, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
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 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:2200 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4347
Practice Address - Country:US
Practice Address - Phone:870-972-1268
Practice Address - Fax:870-934-0847
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2108003101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional