Basic Information
| Provider Information | |||||||||
| NPI: | 1417489774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5003 S MIAMI BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277038589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 8778406694 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 W 8TH ST | ||||||||
| Address2: | 6TH FLOOR, SUITE 6005 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443990 | ||||||||
| FaxNumber: | 9042443455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 86392 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 202100603 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | TRN24684 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.