Provider Demographics
NPI:1205053352
Name:BLACKWELL, JEREMY TY (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TY
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1450 JONES DAIRY ROAD
Mailing Address - Street 2:BLDG 600
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-6109
Mailing Address - Country:US
Mailing Address - Phone:205-387-8159
Mailing Address - Fax:205-387-8262
Practice Address - Street 1:1450 JONES DAIRY ROAD
Practice Address - Street 2:BLDG 900
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-6108
Practice Address - Country:US
Practice Address - Phone:205-387-8159
Practice Address - Fax:205-387-8262
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL27715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine