Provider Demographics
NPI:1467446377
Name:BLANCO, JESSICA ANN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:BLANCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 W CHANDLER BLVD
Mailing Address - Street 2:STE B-13
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3683
Mailing Address - Country:US
Mailing Address - Phone:480-361-4780
Mailing Address - Fax:480-361-4781
Practice Address - Street 1:5505 W CHANDLER BLVD
Practice Address - Street 2:STE B-13
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3683
Practice Address - Country:US
Practice Address - Phone:480-361-4780
Practice Address - Fax:480-361-4781
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ73441Medicare ID - Type Unspecified
H69612Medicare UPIN