Provider Demographics
NPI:1598473860
Name:BLACKWELL JR, JERRY D JR (LAT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:D
Last Name:BLACKWELL JR
Suffix:JR
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2498 PINERIDGE ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3959
Mailing Address - Country:US
Mailing Address - Phone:985-446-7573
Mailing Address - Fax:
Practice Address - Street 1:2498 PINERIDGE ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3959
Practice Address - Country:US
Practice Address - Phone:985-446-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ002352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer