Provider Demographics
NPI:1881656932
Name:BLANCO-DOE, JENNY (AUD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:BLANCO-DOE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 VALLEYGATE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3688
Mailing Address - Country:US
Mailing Address - Phone:910-323-9222
Mailing Address - Fax:910-221-9220
Practice Address - Street 1:2053 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-323-9222
Practice Address - Fax:910-221-9220
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6218231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001503Medicaid