Provider Demographics
NPI:1871865865
Name:BLACKMON, JENNIFER (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 19TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4100
Mailing Address - Country:US
Mailing Address - Phone:757-376-2560
Mailing Address - Fax:
Practice Address - Street 1:700 19TH ST STE 105
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-4100
Practice Address - Country:US
Practice Address - Phone:757-376-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556960111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor