Provider Demographics
NPI:1477524213
Name:BLANK, JACQUELINE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N FINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-1686
Mailing Address - Country:US
Mailing Address - Phone:908-340-4609
Mailing Address - Fax:
Practice Address - Street 1:150 N FINLEY AVE
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-1686
Practice Address - Country:US
Practice Address - Phone:908-340-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07936100207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ094778Medicare PIN
NJI42254Medicare UPIN