Provider Demographics
NPI:1932546728
Name:BLAGG, JIMMY BURT (HIS, HAD)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:BURT
Last Name:BLAGG
Suffix:
Gender:M
Credentials:HIS, HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 MENAUL BLVD NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2260
Mailing Address - Country:US
Mailing Address - Phone:505-299-7777
Mailing Address - Fax:505-299-7777
Practice Address - Street 1:8400 MENAUL BLVD NE
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2260
Practice Address - Country:US
Practice Address - Phone:505-299-7777
Practice Address - Fax:505-299-7777
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0832237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist