Provider Demographics
NPI:1790051225
Name:BLANK, JACELYN (MED)
Entity Type:Individual
Prefix:
First Name:JACELYN
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2064 E YORK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1635
Mailing Address - Country:US
Mailing Address - Phone:215-427-2739
Mailing Address - Fax:
Practice Address - Street 1:2064 E YORK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1635
Practice Address - Country:US
Practice Address - Phone:215-427-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker