Provider Demographics
NPI:1629100797
Name:BLACKER, SUSAN JEAN (QMHA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JEAN
Last Name:BLACKER
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 N WATTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6367
Mailing Address - Country:US
Mailing Address - Phone:503-286-4210
Mailing Address - Fax:
Practice Address - Street 1:3034 NE M L KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3053
Practice Address - Country:US
Practice Address - Phone:503-283-3763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator