Provider Demographics
NPI:1952982340
Name:BLACKWELL, JESSICA (LISW-CP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HILTON GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7525
Mailing Address - Country:US
Mailing Address - Phone:803-719-6103
Mailing Address - Fax:
Practice Address - Street 1:458 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6971
Practice Address - Country:US
Practice Address - Phone:803-549-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical