Provider Demographics
NPI:1538941547
Name:BLACKLOCK, JENNIFER ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:BLACKLOCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NW 42ND ST # NA
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-2575
Mailing Address - Country:US
Mailing Address - Phone:561-414-8978
Mailing Address - Fax:
Practice Address - Street 1:2700 NW 42ND ST # NA
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-2575
Practice Address - Country:US
Practice Address - Phone:561-414-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1517103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool