Provider Demographics
NPI:1760854327
Name:BLACKMON, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
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 1:908 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5844
Mailing Address - Country:US
Mailing Address - Phone:318-547-2312
Mailing Address - Fax:318-325-8749
Practice Address - Street 1:908 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5844
Practice Address - Country:US
Practice Address - Phone:318-547-2312
Practice Address - Fax:318-325-8749
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor