Provider Demographics
NPI:1043704802
Name:BLANCO, JESSICA MARIAN (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIAN
Last Name:BLANCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 DARWIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-9204
Mailing Address - Country:US
Mailing Address - Phone:734-864-6003
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5601010756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician