Provider Demographics
NPI:1912147893
Name:BLYSTONE, JENNIFER WALLY (ATC, EMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:WALLY
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:ATC, EMT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:WALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, EMT
Mailing Address - Street 1:5140 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-9479
Mailing Address - Country:US
Mailing Address - Phone:724-463-9071
Mailing Address - Fax:
Practice Address - Street 1:5140 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-9479
Practice Address - Country:US
Practice Address - Phone:724-463-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001482A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer