Provider Demographics
NPI:1720090202
Name:BLACKBURN, JEAN B (MSN,APN,APRN,BC)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:B
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSN,APN,APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6419 LARAMIE CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1962
Mailing Address - Country:US
Mailing Address - Phone:423-698-8414
Mailing Address - Fax:423-698-8413
Practice Address - Street 1:6419 LARAMIE CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-698-8414
Practice Address - Fax:423-698-8413
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARO96375364SP0808X
TNAPN0000010736364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0184813OtherBLUE CROSS/ BLUE SHIELD
TN621215337OtherIRS IND. TAXPAYER ID#