Healthcare Provider Details

I. General information

NPI: 1558111575
Provider Name (Legal Business Name): JACOB BLACKMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 KIRBY RD
KING NC
27021-9493
US

IV. Provider business mailing address

PO BOX 4370
ARCHDALE NC
27263-4370
US

V. Phone/Fax

Practice location:
  • Phone: 336-983-4313
  • Fax: 336-983-3500
Mailing address:
  • Phone: 336-687-7730
  • Fax: 336-434-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2805
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: