Provider Demographics
NPI:1215216130
Name:BLANTON, GARRETT JASON
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:JASON
Last Name:BLANTON
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 1:24024 NW 196TH TER
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-9032
Mailing Address - Country:US
Mailing Address - Phone:352-328-2919
Mailing Address - Fax:
Practice Address - Street 1:4909 NW 27TH CT
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6509
Practice Address - Country:US
Practice Address - Phone:352-377-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA55181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist