Provider Demographics
NPI:1982232179
Name:BLACKSHIRE, JEREMY (MA, LPC, LMHP, NCC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BLACKSHIRE
Suffix:
Gender:M
Credentials:MA, LPC, LMHP, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6316
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24505-6316
Mailing Address - Country:US
Mailing Address - Phone:540-586-5429
Mailing Address - Fax:
Practice Address - Street 1:1409 OLD DOMINION BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-3285
Practice Address - Country:US
Practice Address - Phone:540-586-5429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008802101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional