Provider Demographics
NPI:1306224795
Name:BLUNT, JACKIE (FNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BLUNT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:PURVINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5313 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1137
Mailing Address - Country:US
Mailing Address - Phone:315-771-1400
Mailing Address - Fax:
Practice Address - Street 1:7668 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1353
Practice Address - Country:US
Practice Address - Phone:315-376-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY610153163W00000X
NY338804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse