Provider Demographics
NPI:1790134328
Name:BLAKELEY, JACQUELINE N (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:N
Last Name:BLAKELEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 FRONTIER DR
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-9734
Mailing Address - Country:US
Mailing Address - Phone:801-876-3749
Mailing Address - Fax:
Practice Address - Street 1:5226 FRONTIER DR
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9734
Practice Address - Country:US
Practice Address - Phone:801-876-3749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-04
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4791430-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care