Provider Demographics
NPI:1093880668
Name:BLANK, JARED (MS PT)
Entity Type:Individual
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First Name:JARED
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:MS PT
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Mailing Address - Street 1:2619 CULVER RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609
Mailing Address - Country:US
Mailing Address - Phone:585-342-2410
Mailing Address - Fax:585-342-9141
Practice Address - Street 1:2619 CULVER RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609
Practice Address - Country:US
Practice Address - Phone:585-342-2410
Practice Address - Fax:585-342-9141
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-06-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY021951-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021951-1OtherPT LICENSE