Healthcare Provider Details

I. General information

NPI: 1679401574
Provider Name (Legal Business Name): JEANNICE BLAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3832 SW 33RD CT
WEST PARK FL
33023-5631
US

IV. Provider business mailing address

9941 SW DAVANTI DR
PORT SAINT LUCIE FL
34987-6716
US

V. Phone/Fax

Practice location:
  • Phone: 954-947-5061
  • Fax: 954-371-2510
Mailing address:
  • Phone: 786-877-4177
  • 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: