Provider Demographics
NPI:1225647308
Name:BLANCO, JESSY
Entity type:Individual
Prefix:MRS
First Name:JESSY
Middle Name:
Last Name:BLANCO
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 1:11180 SW 107TH ST APT 115
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-8249
Mailing Address - Country:US
Mailing Address - Phone:786-523-3787
Mailing Address - Fax:
Practice Address - Street 1:11180 SW 107TH ST APT 115
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-8249
Practice Address - Country:US
Practice Address - Phone:786-523-3787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT20120878106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician