Provider Demographics
NPI:1598015372
Name:BLACKWOOD, JEREMY CLARK
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:CLARK
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 CARDINAL MEDEIROS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1420
Mailing Address - Country:US
Mailing Address - Phone:617-388-2383
Mailing Address - Fax:
Practice Address - Street 1:181 UNION ST STE 2
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1346
Practice Address - Country:US
Practice Address - Phone:978-542-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health