Provider Demographics
NPI:1821252412
Name:BLANK, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BLANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 MOORHEAD AVE
Mailing Address - Street 2:#104
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3373
Mailing Address - Country:US
Mailing Address - Phone:219-221-0393
Mailing Address - Fax:
Practice Address - Street 1:6091 S QUEBEC ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-4521
Practice Address - Country:US
Practice Address - Phone:303-504-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist