Provider Demographics
NPI:1073931788
Name:BLANK, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BLANK
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 1:501 HOWARD AVE STE F2
Mailing Address - Street 2:SUITE F4
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 HOWARD AVE STE F2
Practice Address - Street 2:SUITE F4
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4818
Practice Address - Country:US
Practice Address - Phone:814-889-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461730207RH0002X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine