Provider Demographics
NPI:1336717123
Name:BLAISDELL, JENNIFER C
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:CIVITA
Other - Last Name:HARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:231 STATE ST STE 6
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2785
Mailing Address - Country:US
Mailing Address - Phone:231-881-9125
Mailing Address - Fax:
Practice Address - Street 1:14392 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-4146
Practice Address - Country:US
Practice Address - Phone:734-765-3842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010955311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty