Provider Demographics
NPI:1275928996
Name:BLANKENSHIP, JACQUELINE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 78TH AVE N APT 183
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4469
Mailing Address - Country:US
Mailing Address - Phone:813-495-0186
Mailing Address - Fax:
Practice Address - Street 1:8451 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5441
Practice Address - Country:US
Practice Address - Phone:866-450-9927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6528235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist