Provider Demographics
NPI:1538360227
Name:BLACKMON, BRET
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 NORTHTOWN DR
Mailing Address - Street 2:APT 31J
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 S WHEATLEY ST
Practice Address - Street 2:SUITE 240
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5000
Practice Address - Country:US
Practice Address - Phone:601-572-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor