Provider Demographics
NPI:1811936826
Name:BLACKMAN, JESSE AYCOCK (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:AYCOCK
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5413 US HIGHWAY 117 N
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-9445
Mailing Address - Country:US
Mailing Address - Phone:919-242-5271
Mailing Address - Fax:919-242-5096
Practice Address - Street 1:5413 US HIGHWAY 117 N
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863-9445
Practice Address - Country:US
Practice Address - Phone:919-242-5271
Practice Address - Fax:919-242-5096
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC80790Medicare UPIN