Provider Demographics
NPI:1811021553
Name:BLAIR, JENNIFER R (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:R
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8318 196TH ST SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6434
Mailing Address - Country:US
Mailing Address - Phone:425-640-6134
Mailing Address - Fax:
Practice Address - Street 1:8318 196TH ST SW
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-6434
Practice Address - Country:US
Practice Address - Phone:425-640-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1782103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical