Provider Demographics
NPI:1457747271
Name:BLANCHARD, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E BROADWAY STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8023
Mailing Address - Country:US
Mailing Address - Phone:573-815-8130
Mailing Address - Fax:573-815-8149
Practice Address - Street 1:1605 E BROADWAY STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-8130
Practice Address - Fax:573-815-8149
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018022799213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1457747271Medicaid