Healthcare Provider Details

I. General information

NPI: 1821293242
Provider Name (Legal Business Name): JASON LEE BLACKHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 SE BISHOP BLVD STE 120
PULLMAN WA
99163-5517
US

IV. Provider business mailing address

825 SE BISHOP BLVD STE 120
PULLMAN WA
99163-5517
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-2828
  • Fax:
Mailing address:
  • Phone: 509-332-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD.MD.70131894
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number2981404
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: