Healthcare Provider Details

I. General information

NPI: 1689130676
Provider Name (Legal Business Name): JENESSA RENEA BLEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E 23RD AVE
HUTCHINSON KS
67502-1105
US

IV. Provider business mailing address

9515 W PLEASANT VALLEY RD
PARTRIDGE KS
67566-9041
US

V. Phone/Fax

Practice location:
  • Phone: 620-665-2000
  • Fax:
Mailing address:
  • Phone: 620-899-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number18-00998
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: