Basic Information
| Provider Information | |||||||||
| NPI: | 1811460173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | LEYLA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1940 STONEGATE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352422541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1940 STONEGATE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352422541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2019 | ||||||||
| LastUpdateDate: | 01/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1-162172 | AL | N | Nursing Service Providers | Registered Nurse | 363LF0000X | F09201154 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.