Basic Information
| Provider Information | |||||||||
| NPI: | 1275868952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | JETTIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 N STOCKTON HILL RD STE B | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287573256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1741 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287571199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2009 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12845 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 468913 | 05 | AZ | MEDICAID |