Provider Demographics
NPI:1851074462
Name:BLACKWELL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14418 TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4402
Practice Address - Country:US
Practice Address - Phone:630-631-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician