Individual
JACQUES D BLACKMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
13213 W 21ST ST N, WICHITA, KS 67235-9625
(316) 945-0142
(316) 946-1760
Mailing address
PO BOX 8035, WICHITA, KS 67208-0035
(316) 689-9135
(316) 689-9102
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
17181
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
021348
MEDICARE
—
05
—
100205200A
—
KS
Enumeration date
07/07/2006
Last updated
03/24/2015
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