Provider Demographics
NPI:1679759682
Name:BLAIR-MERRITT, JACKIE LYNN (PT)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNN
Last Name:BLAIR-MERRITT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 E SPRINGFIELD PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-1432
Mailing Address - Country:US
Mailing Address - Phone:480-857-9597
Mailing Address - Fax:
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-512-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist