Provider Demographics
NPI:1023168358
Name:BLACKSTONE, JACQUELYN A (DO)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:BLACKSTONE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-3120
Practice Address - Fax:505-272-8060
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1954-16207VM0101X
ME1379207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME289980099Medicaid
NH30005994Medicaid
ME160045567Medicare PIN
F61902Medicare UPIN
NH30005994Medicaid
ME289980099Medicaid
MEMM4920Medicare PIN