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General NPI Number Information
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NPI Number | 1992181796
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Entity Type | Individual
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Provider Name | JENNIFER ANN BLASER PTA
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Gender | Female
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Dates
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Enumeration Date | 08/04/2015
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Last Update Date | 08/04/2015
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Provider Practice Location Address
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Address Line | 4401 N MAIN ST
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City | ROCKFORD
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State | IL
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Zip | 61103-1277
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Country | US
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Telephone | 779-771-6866
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Fax |
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Provider Business Mailing Address
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Address Line | W7518 MELVIN RD
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City | BROWNTOWN
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State | WI
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Zip | 53522-9709
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Country | US
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Telephone | 608-214-6548
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160006093
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License Number State | IL
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