Provider Demographics
NPI:1881171403
Name:BLAISDELL, JILLIAN CLARK
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:CLARK
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 W RIVER ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2615
Mailing Address - Country:US
Mailing Address - Phone:401-616-1719
Mailing Address - Fax:401-727-1979
Practice Address - Street 1:148 W RIVER ST STE 2A
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2615
Practice Address - Country:US
Practice Address - Phone:401-616-1719
Practice Address - Fax:401-727-1979
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAUD00242231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist