Provider Demographics
NPI:1871137034
Name:BLACKWELL, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KENSINGTON AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5670
Mailing Address - Country:US
Mailing Address - Phone:406-201-6501
Mailing Address - Fax:
Practice Address - Street 1:800 KENSINGTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5670
Practice Address - Country:US
Practice Address - Phone:406-201-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-33154101YA0400X
MTBBH-SWLC-LIC-483551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical