1710477872 NPI number — MRS. JENNAE C BLATTNER MS, OTRL

Table of content: MRS. JENNAE C BLATTNER MS, OTRL (NPI 1710477872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710477872 NPI number — MRS. JENNAE C BLATTNER MS, OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLATTNER
Provider First Name:
JENNAE
Provider Middle Name:
C
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALLEN
Provider Other First Name:
JENNAE
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710477872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3153 E CRYSTAL WATERS DR UNIT 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49424-8090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
243 WILEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49406-5108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-857-2141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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