Provider Demographics
NPI:1346915378
Name:BLITSTEIN, JACOB SAMUEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SAMUEL
Last Name:BLITSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N CALIFORNIA ST.
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-547-5941
Mailing Address - Fax:
Practice Address - Street 1:1800 N CALIFORNIA ST.
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-547-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2022-07-28
Deactivation Date:2022-04-10
Deactivation Code:
Reactivation Date:2022-07-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
S01294832OtherSTUDENT. HEALTH INSURANCE PLAN (WELLFLEET INSURANCE COMPANY)
CAS01294832OtherSTUDENT HEALTH INSURANCE PLAN (WELLFLEET INSURANCE COMPANY)