Provider Demographics
NPI:1336179712
Name:BLANFORD, AMY JO (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:BLANFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1440 W WALNUT ST
Mailing Address - Street 2:BUILDING #2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1143
Mailing Address - Country:US
Mailing Address - Phone:217-245-1455
Mailing Address - Fax:217-243-6903
Practice Address - Street 1:1440 W WALNUT ST
Practice Address - Street 2:BUILDING #2
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1143
Practice Address - Country:US
Practice Address - Phone:217-245-1455
Practice Address - Fax:217-243-6903
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141-989OtherHEALTHLINK
IL216653OtherGROUP PTAN
IL5415281OtherBLUE CROSS BLUE SHIELD
IL5415281OtherBLUE CROSS BLUE SHIELD
IL216653OtherGROUP PTAN