Healthcare Provider Details

I. General information

NPI: 1124193990
Provider Name (Legal Business Name): JILL BLODGET FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 FAIR OAKS BOULEVARD STATION 4
SACRAMENTO CA
95825
US

IV. Provider business mailing address

4601 BROOKSIDE RD
CAMERON PARK CA
95682-9692
US

V. Phone/Fax

Practice location:
  • Phone: 916-480-6433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10080
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: