Provider Demographics
NPI:1679820567
Name:BLOUNT, JESSA R (CGC)
Entity type:Individual
Prefix:MRS
First Name:JESSA
Middle Name:R
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 KEMPSVILLE RD
Mailing Address - Street 2:STE 1000
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3931
Mailing Address - Country:US
Mailing Address - Phone:757-261-5000
Mailing Address - Fax:757-962-5610
Practice Address - Street 1:880 KEMPSVILLE RD
Practice Address - Street 2:STE 1000
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3931
Practice Address - Country:US
Practice Address - Phone:757-261-5000
Practice Address - Fax:757-962-5610
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14235170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER