Healthcare Provider Details

I. General information

NPI: 1346580446
Provider Name (Legal Business Name): JESSICA CHANE BLAND NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 VAN GORDON ST
LAKEWOOD CO
80228-1709
US

IV. Provider business mailing address

PO BOX 7172
CHARLOTTE NC
28241-7172
US

V. Phone/Fax

Practice location:
  • Phone: 866-633-8846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number243895
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG06200310
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: