MEDICARE: MR. JASON D BLACKWELL

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	1041C0700X	Clinical Social Worker
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1528747169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON D BLACKWELL

Provider Business Mailing Address
First Line	:	36 RUSS ST FL 1
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1520
Country	:	US
Telephone Number	:	914-772-4363
Fax Number	:	860-200-0761

Provider Business Practice Location Address
First Line	:	36 RUSS ST FL 1
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1520
Country	:	US
Telephone Number	:	914-772-4363
Fax Number	:	860-200-0761

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

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	07/12/2023

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Directions to “ MR. JASON D BLACKWELL ” Practice Location

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