Provider Demographics
NPI:1184048332
Name:BLAZKA, JESSICA LOUISE (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:BLAZKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-0706
Mailing Address - Country:US
Mailing Address - Phone:603-481-8757
Mailing Address - Fax:603-238-2163
Practice Address - Street 1:87 MCGREGOR ST STE 3100
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3766
Practice Address - Country:US
Practice Address - Phone:603-627-1887
Practice Address - Fax:603-536-1544
Is Sole Proprietor?:No
Enumeration Date:2014-02-08
Last Update Date:2021-04-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NH0996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3095759Medicaid
NH3095759Medicaid