Provider Demographics
NPI:1003451097
Name:LAGERBLADE, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:LAGERBLADE
Suffix:
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 1:20 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-2952
Mailing Address - Country:US
Mailing Address - Phone:781-715-2390
Mailing Address - Fax:781-715-2423
Practice Address - Street 1:20 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-2952
Practice Address - Country:US
Practice Address - Phone:781-715-2390
Practice Address - Fax:781-715-2423
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN93551164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse