Provider Demographics
NPI:1922408996
Name:BLACKBURN, JACKIE LYNN
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:BLACKBURN
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 1:32 BLACKBURN LN
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-6800
Mailing Address - Country:US
Mailing Address - Phone:606-434-8105
Mailing Address - Fax:
Practice Address - Street 1:104 S FRONT AVE
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1614
Practice Address - Country:US
Practice Address - Phone:606-886-8572
Practice Address - Fax:606-886-4433
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health