Individual
GAVIN BLACKWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
115 QUAIL RDG, JACKSON, TN 38305-5420
(731) 803-0654
Mailing address
115 QUAIL RDG, JACKSON, TN 38305-5420
(731) 803-0654
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
0000006264
TN
Other
Enumeration date
11/17/2016
Last updated
11/17/2016
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