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General NPI Number Information
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NPI Number | 1417489774
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Entity Type | Individual
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Provider Name | LEE BLACKMON
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Gender | Male
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 09/29/2021
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Provider Practice Location Address
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Address Line | 580 W 8TH ST 6TH FLOOR, SUITE 6005
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City | JACKSONVILLE
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State | FL
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Zip | 32209-6533
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Country | US
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Telephone | 904-244-3990
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Fax | 904-244-3455
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Provider Business Mailing Address
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Address Line | 5003 S MIAMI BLVD STE 300
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City | DURHAM
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State | NC
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Zip | 27703-8589
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Country | US
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Telephone | 919-354-0840
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Fax | 877-840-6694
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 86392
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 202100603
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | TRN24684
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License Number State | FL
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