Basic Information
Provider Information
NPI: 1003144171
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLACKWELL
FirstName: JEANINNE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PMHNP-BC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1061 PLEASANT ST
Address2:  
City: NEW BEDFORD
State: MA
PostalCode: 027406728
CountryCode: US
TelephoneNumber: 5089845566
FaxNumber:  
Practice Location
Address1: 543 NORTH ST
Address2:  
City: NEW BEDFORD
State: MA
PostalCode: 027402782
CountryCode: US
TelephoneNumber: 5089845566
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/30/2009
LastUpdateDate: 05/08/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LP0808XRN2313081MAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health
363LP0808XRN2313081DEN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health
363LP0808XR205720MDN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health

No ID Information.


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