Provider Demographics
NPI:1235300054
Name:BLANTON, JACQUELINE D (ACNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:BLANTON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N WASHINGTON ST
Mailing Address - Street 2:STE. 300
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8245
Mailing Address - Country:US
Mailing Address - Phone:931-393-4995
Mailing Address - Fax:931-393-3573
Practice Address - Street 1:1801 N WASHINGTON ST
Practice Address - Street 2:STE. 300
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8245
Practice Address - Country:US
Practice Address - Phone:931-393-4995
Practice Address - Fax:931-393-3573
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3341754Medicaid
TN3341754Medicaid