Provider Demographics
NPI:1588799589
Name:BLEZIO, JACKQUELINE (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:JACKQUELINE
Middle Name:
Last Name:BLEZIO
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11428 SW 74TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2683
Mailing Address - Country:US
Mailing Address - Phone:305-630-3795
Mailing Address - Fax:
Practice Address - Street 1:20700 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1146
Practice Address - Country:US
Practice Address - Phone:305-933-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7994235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA7994OtherLICENSE