Provider Demographics
NPI:1558733493
Name:BLACKWELL, JENNIFER (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 FIELD ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2133
Mailing Address - Country:US
Mailing Address - Phone:508-979-5557
Mailing Address - Fax:508-979-5955
Practice Address - Street 1:226 FIELD ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2133
Practice Address - Country:US
Practice Address - Phone:508-979-5557
Practice Address - Fax:508-979-5955
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000186132Medicaid