Healthcare Provider Details

I. General information

NPI: 1346525623
Provider Name (Legal Business Name): JENNA AMBER BLANCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 CAMINO DEL RIO S 240
SAN DIEGO CA
92108-3607
US

IV. Provider business mailing address

12345 LAKESHORE DR APT 22
LAKESIDE CA
92040-3047
US

V. Phone/Fax

Practice location:
  • Phone: 619-715-5180
  • Fax:
Mailing address:
  • Phone: 619-715-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number21298
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number21298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: