Provider Demographics
NPI:1982232179
Name:BLACKSHIRE, JEREMY (MA, LPC, LMHP, LSATP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BLACKSHIRE
Suffix:
Gender:M
Credentials:MA, LPC, LMHP, LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20276 TIMBERLAKE RD STE A
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7214
Mailing Address - Country:US
Mailing Address - Phone:434-319-5528
Mailing Address - Fax:
Practice Address - Street 1:20276 TIMBERLAKE RD STE A
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7214
Practice Address - Country:US
Practice Address - Phone:434-319-5528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008802101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional