Healthcare Provider Details

I. General information

NPI: 1629255609
Provider Name (Legal Business Name): MARK JEFFREY BLANTON SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 11/09/2025
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 N SONORA AVE
FRESNO CA
93722-3966
US

IV. Provider business mailing address

4705 N SONORA AVE STE 113
FRESNO CA
93722-3965
US

V. Phone/Fax

Practice location:
  • Phone: 559-276-7558
  • Fax: 559-276-7568
Mailing address:
  • Phone: 559-276-7558
  • Fax: 559-276-7568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: