Provider Demographics
NPI:1447716766
Name:BLACKWELL, JESSICA MENA (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MENA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 GRANTLAND PL
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-1420
Mailing Address - Country:US
Mailing Address - Phone:205-396-4008
Mailing Address - Fax:
Practice Address - Street 1:2010 BROOKWOOD MEDICAL CTR DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6804
Practice Address - Country:US
Practice Address - Phone:205-877-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1883363AM0700X
AL1456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1336101401Medicaid