Provider Demographics
NPI:1669642401
Name:JESSICA BLANCO MD PC
Entity Type:Organization
Organization Name:JESSICA BLANCO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-361-4780
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ764284Medicaid
AZH69612Medicare UPIN