Healthcare Provider Details

I. General information

NPI: 1174430821
Provider Name (Legal Business Name): JACLYN ANNE BLANSET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 E ARROW HWY UNIT 7
GLENDORA CA
91740-5687
US

IV. Provider business mailing address

297 E ARROW HWY UNIT 7
GLENDORA CA
91740-5687
US

V. Phone/Fax

Practice location:
  • Phone: 909-755-5220
  • Fax:
Mailing address:
  • Phone: 909-755-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: