Provider Demographics
NPI:1730121344
Name:BLAIR, COURTNEY JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:JACKSON
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1360 BEVERLY RD
Mailing Address - Street 2:STE 103
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3621
Mailing Address - Country:US
Mailing Address - Phone:703-356-8290
Mailing Address - Fax:703-356-8031
Practice Address - Street 1:6888 ELM ST STE 301
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3829
Practice Address - Country:US
Practice Address - Phone:703-356-8290
Practice Address - Fax:703-356-8031
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36113297207R00000X, 208000000X
VA0101243347207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics