Provider Demographics
NPI:1578093225
Name:BLANCHETTI, JASON (NP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BLANCHETTI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3803
Mailing Address - Country:US
Mailing Address - Phone:217-464-1440
Mailing Address - Fax:217-464-1469
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1440
Practice Address - Fax:217-464-1469
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner