Provider Demographics
NPI:1689130676
Name:BLEW, JENESSA RENEA
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:RENEA
Last Name:BLEW
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 1:9515 W PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PARTRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67566-9041
Mailing Address - Country:US
Mailing Address - Phone:620-899-0315
Mailing Address - Fax:
Practice Address - Street 1:1701 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1105
Practice Address - Country:US
Practice Address - Phone:620-665-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00998224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS18-00998OtherKANSAS BOARD OF HEALING ARTS