Provider Demographics
NPI:1235457631
Name:BLAYLOCK, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3591 MCKINNEY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-9572
Mailing Address - Country:US
Mailing Address - Phone:972-837-1075
Mailing Address - Fax:972-837-4120
Practice Address - Street 1:3591 MCKINNEY ST STE 100
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454
Practice Address - Country:US
Practice Address - Phone:972-837-1075
Practice Address - Fax:972-837-4120
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041353149163W00000X
TX898686163W00000X
IL209-008242363L00000X
TXAP131058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner