Provider Demographics
NPI:1689150310
Name:BLACKMON, JIMMIE M
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:M
Last Name:BLACKMON
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 1:2701 N ROCKY POINT DR STE 650
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5999
Mailing Address - Country:US
Mailing Address - Phone:800-434-4686
Mailing Address - Fax:
Practice Address - Street 1:2737 CENTERVIEW DRIVE KNIGHT BUILDING
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32399
Practice Address - Country:US
Practice Address - Phone:850-488-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical