Healthcare Provider Details

I. General information

NPI: 1215260591
Provider Name (Legal Business Name): JEREMY BLANK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 12/16/2023
Certification Date: 12/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27403 YNEZ RD STE 205
TEMECULA CA
92591-4616
US

IV. Provider business mailing address

27403 YNEZ RD STE 205
TEMECULA CA
92591-4616
US

V. Phone/Fax

Practice location:
  • Phone: 951-595-7386
  • Fax: 951-414-3770
Mailing address:
  • Phone: 951-595-7386
  • Fax: 951-414-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27148
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY27148
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: