Healthcare Provider Details

I. General information

NPI: 1306344049
Provider Name (Legal Business Name): JASON BARRY BLACKBURN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

21921 TROMBLY ST
SAINT CLAIR SHORES MI
48080-1282
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-2037
  • Fax:
Mailing address:
  • Phone: 586-899-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704286557
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: