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General NPI Number Information
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NPI Number | 1205053352
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Entity Type | Individual
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Provider Name | JEREMY TY BLACKWELL M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 02/01/2013
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Provider Practice Location Address
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Address Line | 1450 JONES DAIRY ROAD BLDG 900
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City | JASPER
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State | AL
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Zip | 35501-6108
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Country | US
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Telephone | 205-387-8159
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Fax | 205-387-8262
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Provider Business Mailing Address
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Address Line | 1450 JONES DAIRY ROAD BLDG 600
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City | JASPER
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State | AL
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Zip | 35501-6109
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Country | US
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Telephone | 205-387-8159
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Fax | 205-387-8262
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 27715
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License Number State | AL
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