Individual
JETTIE A. BLANTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSW, LCSW
Contact information
Practice address
1741 SYCAMORE AVE, KINGMAN, AZ 86409-0927
(928) 757-8111
(928) 757-1199
Mailing address
3707 N STOCKTON HILL RD STE B, KINGMAN, AZ 86409-0507
(928) 757-8111
(928) 757-3256
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
12845
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
468913
—
AZ
Enumeration date
10/13/2009
Last updated
09/13/2022
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