Provider Demographics
NPI:1346525623
Name:BLANCHARD, JENNA AMBER
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:AMBER
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 LAKESHORE DR APT 22
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3047
Mailing Address - Country:US
Mailing Address - Phone:619-715-5180
Mailing Address - Fax:
Practice Address - Street 1:2333 CAMINO DEL RIO S
Practice Address - Street 2:240
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3607
Practice Address - Country:US
Practice Address - Phone:619-715-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21298172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist