Provider Demographics
NPI:1093975948
Name:BLASCOE, JEAN MARIE (CPNP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:BLASCOE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14790 EAGLE RIDGE DR
Mailing Address - Street 2:APT 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1791
Mailing Address - Country:US
Mailing Address - Phone:815-494-0623
Mailing Address - Fax:239-939-4794
Practice Address - Street 1:3830 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9305
Practice Address - Country:US
Practice Address - Phone:239-939-2808
Practice Address - Fax:239-939-4794
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309003042363LP0200X
FL9366764363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics