Healthcare Provider Details

I. General information

NPI: 1619916186
Provider Name (Legal Business Name): JONATHAN BLACKMON IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 WILD GRAPE DR
SAINT MARYS GA
31558-3619
US

IV. Provider business mailing address

881 USS JAMES MADISON RD NAVAL SUBMARINE SUPPORT CENTER MEDICAL DEPARTMENT
KINGS BAY GA
31547-2531
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-2940
  • Fax:
Mailing address:
  • Phone: 912-573-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: