MEDICARE: JILLIAN M BLANK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1194438309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN M BLANK

Provider Business Mailing Address
First Line	:	PO BOX 2021
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-0021
Country	:	US
Telephone Number	:	707-395-5971
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 2021
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-0021
Country	:	US
Telephone Number	:	707-765-8488
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2023
Last Update Date	:	02/05/2026

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