Basic Information
| Provider Information | |||||||||
| NPI: | 1659550184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONDE | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 731 MAIN ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064682872 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 731 MAIN ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064682872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032617090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 006539 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.