Provider Demographics
NPI:1245359512
Name:BLANKE, JENNIFER L (DPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:BLANKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2814 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4640
Mailing Address - Country:US
Mailing Address - Phone:660-785-1834
Mailing Address - Fax:
Practice Address - Street 1:2814 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-785-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO481363000Medicaid