Provider Demographics
NPI:1710859541
Name:BLAKELY, JAMES AUSTIN
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:AUSTIN
Last Name:BLAKELY
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 1:3609 COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2812
Mailing Address - Country:US
Mailing Address - Phone:843-229-9311
Mailing Address - Fax:843-229-9311
Practice Address - Street 1:3609 COLEMAN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2812
Practice Address - Country:US
Practice Address - Phone:843-229-9311
Practice Address - Fax:843-229-9311
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program