Basic Information
| Provider Information | |||||||||
| NPI: | 1982941647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1230 N ANDERSON RD | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932219674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595944855 | ||||||||
| FaxNumber: | 5595944335 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 N ANDERSON RD | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932219674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595944855 | ||||||||
| FaxNumber: | 5595944335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 85029 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.