Provider Demographics
NPI:1740765544
Name:GOLDBLATT, JESSE (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11250 SSG SIMS ST
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918-8040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11250 SSG SIMS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918-8040
Practice Address - Country:US
Practice Address - Phone:915-742-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2023-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40071103TC0700X
WA61016862103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical