Healthcare Provider Details

I. General information

NPI: 1720090202
Provider Name (Legal Business Name): JEAN B BLACKBURN MSN,APN,APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6419 LARAMIE CIR
CHATTANOOGA TN
37421
US

IV. Provider business mailing address

6419 LARAMIE CIR
CHATTANOOGA TN
37421-1962
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-8414
  • Fax: 423-698-8413
Mailing address:
  • Phone: 423-698-8414
  • Fax: 423-698-8413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberRO96375
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberAPN0000010736
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: