Provider Demographics
NPI:1902172646
Name:BLAIR, JENNIFER ANN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BLAIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S TEBO ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:MO
Mailing Address - Zip Code:65360-1161
Mailing Address - Country:US
Mailing Address - Phone:660-647-2147
Mailing Address - Fax:660-647-2160
Practice Address - Street 1:100 S TEBO ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:MO
Practice Address - Zip Code:65360-1161
Practice Address - Country:US
Practice Address - Phone:660-647-2147
Practice Address - Fax:660-647-2160
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1902172646Medicaid
MO1902172646Medicaid