Provider Demographics
NPI:1689063760
Name:OFFUTT-BLACKABY, JO SUSAN (MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:SUSAN
Last Name:OFFUTT-BLACKABY
Suffix:
Gender:F
Credentials:MSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 MAGGIE CT
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:TN
Mailing Address - Zip Code:37073-0500
Mailing Address - Country:US
Mailing Address - Phone:615-970-9467
Mailing Address - Fax:615-246-9030
Practice Address - Street 1:2006 MAGGIE CT
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:TN
Practice Address - Zip Code:37073-0500
Practice Address - Country:US
Practice Address - Phone:615-620-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25460363LP0808X
TN19574364SP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3335OtherMEDICARE
SC421504Medicaid