Provider Demographics
NPI:1295837383
Name:BLANKENSHIP, SUSAN LOUISE (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LOUISE
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1012
Mailing Address - Country:US
Mailing Address - Phone:517-960-4528
Mailing Address - Fax:517-676-1184
Practice Address - Street 1:505 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1012
Practice Address - Country:US
Practice Address - Phone:517-960-4528
Practice Address - Fax:517-676-1184
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0335721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM56190Medicare ID - Type Unspecified