Basic Information
| Provider Information | |||||||||
| NPI: | 1467027896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5010 HICONE RD | ||||||||
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| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274059429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365299816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.