Provider Demographics
NPI:1821274408
Name:BLAIR, JACKIE C (MED)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:C
Last Name:BLAIR
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 1:177 E MEADOWLARK
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5116
Mailing Address - Country:US
Mailing Address - Phone:928-243-1250
Mailing Address - Fax:
Practice Address - Street 1:146 SCHOOL BUS LANE
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937
Practice Address - Country:US
Practice Address - Phone:928-536-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86020236101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86020236Medicaid