Provider Demographics
NPI:1073113627
Name:BLASDEL, JESSICAH
Entity Type:Individual
Prefix:
First Name:JESSICAH
Middle Name:
Last Name:BLASDEL
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 1771
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-1771
Mailing Address - Country:US
Mailing Address - Phone:405-659-3705
Mailing Address - Fax:
Practice Address - Street 1:320 ROBERT S KERR AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-3457
Practice Address - Country:US
Practice Address - Phone:877-868-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily