Provider Demographics
NPI:1386012631
Name:BLANCH, JACQUELINE (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BLANCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:602-470-5064
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-470-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ285348363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN174076OtherAZ BOARD OF NURSING