=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104477439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL R BLOCKER CNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2019
-----------------------------------------------------
Last Update Date | 09/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 CANTERBURY LN
-----------------------------------------------------
City | WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06095-2065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-219-9723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 521
-----------------------------------------------------
City | WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06095-0521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-837-1130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | CT091303632E
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------