Provider Demographics
NPI:1336025600
Name:BLACKARD, JON LEE
Entity type:Individual
Prefix:
First Name:JON
Middle Name:LEE
Last Name:BLACKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TATHAS
Other - Middle Name:
Other - Last Name:BLACKARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5328 LANIER ISLANDS PKWY # 101
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-9071
Mailing Address - Country:US
Mailing Address - Phone:470-655-1970
Mailing Address - Fax:470-655-1970
Practice Address - Street 1:5328 LANIER ISLANDS PKWY # 101
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-9071
Practice Address - Country:US
Practice Address - Phone:470-655-1970
Practice Address - Fax:470-655-1970
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician