Provider Demographics
NPI:1982893731
Name:BLACKMAN, JEAN JETTA (PHARMACY TECHNICIAN)
Entity Type:Individual
Prefix:MISS
First Name:JEAN
Middle Name:JETTA
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6518 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-1909
Mailing Address - Country:US
Mailing Address - Phone:215-729-2405
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2225
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:610-825-1604
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA604178183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician