Provider Demographics
NPI:1063971976
Name:BLASCHKO-IVELAND, JACOB (AUD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BLASCHKO-IVELAND
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:DR
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:IVELAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AUD
Mailing Address - Street 1:3734 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2513
Mailing Address - Country:US
Mailing Address - Phone:507-995-8875
Mailing Address - Fax:
Practice Address - Street 1:3734 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2513
Practice Address - Country:US
Practice Address - Phone:310-375-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12464390200000X
CA3454237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty