Healthcare Provider Details

I. General information

NPI: 1275868952
Provider Name (Legal Business Name): JETTIE A. BLANTON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 SYCAMORE AVE
KINGMAN AZ
86409-0927
US

IV. Provider business mailing address

3707 N STOCKTON HILL RD STE B
KINGMAN AZ
86409-0507
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8111
  • Fax: 928-757-1199
Mailing address:
  • Phone: 928-757-8111
  • Fax: 928-757-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: