Provider Demographics
NPI:1649559014
Name:BLACKMORE, JARED (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:BLACKMORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10506A MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4402
Mailing Address - Country:US
Mailing Address - Phone:513-865-5120
Mailing Address - Fax:513-865-9875
Practice Address - Street 1:10506A MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-5120
Practice Address - Fax:513-865-9875
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067767Medicaid
OH0067767Medicaid