Provider Demographics
NPI:1689370769
Name:BLACKMON, JAQUELINE DARE (PMHNP)
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:DARE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 CLIMBING DAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-4949
Mailing Address - Country:US
Mailing Address - Phone:910-584-0980
Mailing Address - Fax:
Practice Address - Street 1:1610 CLIMBING DAYFLOWER DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-4949
Practice Address - Country:US
Practice Address - Phone:910-584-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11024186363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health