MEDICARE: JUANITA BLACKMON MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1033764485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA BLACKMON MS

Provider Business Mailing Address
First Line	:	5904 S KEDZIE AVE APT 303
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3216
Country	:	US
Telephone Number	:	312-342-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	5904 S KEDZIE AVE APT 303
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3216
Country	:	US
Telephone Number	:	312-342-9118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2019
Last Update Date	:	08/02/2019

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