Healthcare Provider Details

I. General information

NPI: 1669916797
Provider Name (Legal Business Name): JASON BLACKBURN C.P.S.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 WESTBANK EXPY SUITE 550
HARVEY LA
70058-4366
US

IV. Provider business mailing address

1901 WESTBANK EXPY SUITE 550
HARVEY LA
70058-4366
US

V. Phone/Fax

Practice location:
  • Phone: 504-247-9120
  • Fax: 504-247-9125
Mailing address:
  • Phone: 504-247-9120
  • Fax: 504-247-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: