Provider Demographics
NPI:1194438309
Name:BLANK, JILLIAN M
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:M
Last Name:BLANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 ELM DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7618
Mailing Address - Country:US
Mailing Address - Phone:707-696-2197
Mailing Address - Fax:
Practice Address - Street 1:1500 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5545
Practice Address - Country:US
Practice Address - Phone:707-765-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program