Provider Demographics
NPI:1417234675
Name:BLAZO, JESSE RAYMOND (LAC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:RAYMOND
Last Name:BLAZO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 15TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2293
Mailing Address - Country:US
Mailing Address - Phone:510-393-3015
Mailing Address - Fax:
Practice Address - Street 1:1904 FRANKLIN ST STE 500
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2926
Practice Address - Country:US
Practice Address - Phone:510-817-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13903171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist