Provider Demographics
NPI:1558733493
Name:BLACKWELL, JENNIFER (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 LAKE OTIS PKWY STE 303
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5226
Mailing Address - Country:US
Mailing Address - Phone:907-600-5212
Mailing Address - Fax:907-600-1026
Practice Address - Street 1:4200 LAKE OTIS PKWY STE 303
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5226
Practice Address - Country:US
Practice Address - Phone:907-600-5212
Practice Address - Fax:907-600-1026
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006063363AM0700X
MAPA8212363AM0700X
AK239153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000186132Medicaid