Provider Demographics
NPI:1548355506
Name:BLACKWELL-WHITE, JACALYN CECELIA (MD)
Entity type:Individual
Prefix:DR
First Name:JACALYN
Middle Name:CECELIA
Last Name:BLACKWELL-WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5400 OLD COURT RD STE 300B
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5100
Mailing Address - Country:US
Mailing Address - Phone:410-521-7337
Mailing Address - Fax:410-521-7377
Practice Address - Street 1:5400 OLD COURT RD STE 300B
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-521-7337
Practice Address - Fax:410-521-7377
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD351872080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD443261400Medicaid
MD1789JOtherCAREFIRST
MD443261400Medicaid