Provider Demographics
NPI:1053195859
Name:BLACKSON, DEDDRICKA
Entity type:Individual
Prefix:MS
First Name:DEDDRICKA
Middle Name:
Last Name:BLACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77053
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70879-7053
Mailing Address - Country:US
Mailing Address - Phone:225-278-8375
Mailing Address - Fax:225-756-4495
Practice Address - Street 1:1401 HUDSON LN STE 139
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6037
Practice Address - Country:US
Practice Address - Phone:318-651-0086
Practice Address - Fax:318-651-0087
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator