MEDICARE: JENNIFER BLAYLOCK FNP

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	363LF0000X	Family Nurse Practitioner	A172505	IA
2	363LP2300X	Primary Care Nurse Practitioner	A172505	IA

General Provider Information

NPI Number	:	1316651524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER BLAYLOCK FNP

Provider Business Mailing Address
First Line	:	15196 NW 16TH ST
Second Line	:
City	:	SLATER
State	:	IA
Zip	:	50244-8019
Country	:	US
Telephone Number	:	515-619-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 S 3RD ST
Second Line	:
City	:	POLK CITY
State	:	IA
Zip	:	50226-1130
Country	:	US
Telephone Number	:	515-986-6426
Fax Number	:

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

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	03/25/2024

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