Provider Demographics
NPI:1669245650
Name:BLANCHARD, JENNA MAE (LADC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MAE
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MAE
Other - Last Name:RICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 INDUS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-9548
Mailing Address - Country:US
Mailing Address - Phone:701-899-2803
Mailing Address - Fax:
Practice Address - Street 1:1100 INDUS ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-9548
Practice Address - Country:US
Practice Address - Phone:701-899-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)