Provider Demographics
NPI:1689037459
Name:BLANCO, JENIFER
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 SEDONA PASEO LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8287
Mailing Address - Country:US
Mailing Address - Phone:818-371-6495
Mailing Address - Fax:
Practice Address - Street 1:3050 E BONANZA RD STE 110B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3706
Practice Address - Country:US
Practice Address - Phone:702-754-0606
Practice Address - Fax:702-754-0605
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036582225100000X
NV4116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist