Provider Demographics
NPI:1235687153
Name:BLYTHE, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:BLYTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 S BRICE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-4183
Mailing Address - Country:US
Mailing Address - Phone:480-694-3542
Mailing Address - Fax:
Practice Address - Street 1:4121 S BRICE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-4183
Practice Address - Country:US
Practice Address - Phone:480-694-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6083377171M00000X
385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child