Provider Demographics
NPI:1558111575
Name:BLACKMAN, JACOB (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 TALUS RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9725
Mailing Address - Country:US
Mailing Address - Phone:910-384-7254
Mailing Address - Fax:
Practice Address - Street 1:1245 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2211
Practice Address - Country:US
Practice Address - Phone:901-722-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program