Provider Demographics
NPI:1770102238
Name:BLAYLOCK, JAMES L (LPT-LMHW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:L
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:LPT-LMHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-2231
Mailing Address - Country:US
Mailing Address - Phone:559-623-3582
Mailing Address - Fax:
Practice Address - Street 1:3133 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1425
Practice Address - Country:US
Practice Address - Phone:559-600-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35805167G00000X
167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician