Provider Demographics
NPI:1336959956
Name:BLACKMON, JOVAN DENIRO JR
Entity type:Individual
Prefix:MR
First Name:JOVAN
Middle Name:DENIRO
Last Name:BLACKMON
Suffix:JR
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 1:3028 N AVENIDA REPUBLICA DE CUBA APT 109
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-2705
Mailing Address - Country:US
Mailing Address - Phone:813-279-0140
Mailing Address - Fax:
Practice Address - Street 1:5447 E BEAUMONT CENTER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5210
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician