Healthcare Provider Details

I. General information

NPI: 1437028677
Provider Name (Legal Business Name): JESSICA MARIE BLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 BRIDGE ST
ARROYO GRANDE CA
93420-3311
US

IV. Provider business mailing address

PO BOX 15408
SAN LUIS OBISPO CA
93406-5408
US

V. Phone/Fax

Practice location:
  • Phone: 805-305-3724
  • Fax:
Mailing address:
  • Phone: 805-540-6500
  • Fax: 805-540-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: