Provider Demographics
NPI:1689652992
Name:BLUMENTHAL, JESSICA ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:MD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-636-9270
Mailing Address - Fax:704-636-1095
Practice Address - Street 1:911 WEST HENDERSON STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2700
Practice Address - Country:US
Practice Address - Phone:704-636-9270
Practice Address - Fax:704-636-1095
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000362207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126PYMedicaid
NC89126PYMedicaid
2280404Medicare ID - Type Unspecified