Provider Demographics
NPI:1295074284
Name:BLACKMON, BENJAMIN AMOS II
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:AMOS
Last Name:BLACKMON
Suffix:II
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 1:111 MYRTLE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2535
Mailing Address - Country:US
Mailing Address - Phone:510-839-3800
Mailing Address - Fax:
Practice Address - Street 1:111 MYRTLE ST STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2535
Practice Address - Country:US
Practice Address - Phone:510-839-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health