Provider Demographics
NPI:1457116303
Name:BLAZOVICH, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BLAZOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 E 2100 S APT 726
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-6805
Mailing Address - Country:US
Mailing Address - Phone:307-371-2628
Mailing Address - Fax:
Practice Address - Street 1:1155 E 2100 S APT 726
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-6805
Practice Address - Country:US
Practice Address - Phone:307-371-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14412220235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty