Healthcare Provider Details

I. General information

NPI: 1144933367
Provider Name (Legal Business Name): JENNIFER BLACKERBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BRIARWOOD AVE
MIDLAND TX
79707-2753
US

IV. Provider business mailing address

5000 BRIARWOOD AVE
MIDLAND TX
79707-2753
US

V. Phone/Fax

Practice location:
  • Phone: 432-682-5385
  • Fax:
Mailing address:
  • Phone: 432-682-5385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA17192
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: