Provider Demographics
NPI:1750449658
Name:BLANTON, JEFFREY S (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:BLANTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W BLACKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-2801
Mailing Address - Country:US
Mailing Address - Phone:580-363-2211
Mailing Address - Fax:
Practice Address - Street 1:113 W BLACKWELL AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-2801
Practice Address - Country:US
Practice Address - Phone:580-363-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor