Provider Demographics
NPI:1629394986
Name:BLEVINS, JENNIFER (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:NV
Mailing Address - Zip Code:89442-0280
Mailing Address - Country:US
Mailing Address - Phone:775-352-6840
Mailing Address - Fax:775-352-6840
Practice Address - Street 1:104 BIG BEND RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:NV
Practice Address - Zip Code:89442
Practice Address - Country:US
Practice Address - Phone:775-352-6840
Practice Address - Fax:775-352-6840
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA750866163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid