Recently Updated NPI Information — some details in this NPI profile have been updated in the NPI registry within the last 60 days.

JACOB ROBERT BLANK DO
NPI 1619618907
Student in an Organized Health Care Education/Training Program in Phoenix, AZ

Q: What is Jacob Blank's NPI number?

The NPI number for Jacob Blank is 1619618907. It was assigned to this individual provider in the NPPES registry on April 2, 2022.

Q: What is Jacob Blank's specialty?

The primary specialty registered for this NPI is Student in an Organized Health Care Education/Training Program with taxonomy code 390200000X.

Q: When was this NPI record last updated?

The NPPES record for Jacob Blank was last updated on August 31, 2026. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 16 days ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since April 02, 2022PECOS Enrolled

775 E WILLETTA ST, PHOENIX, AZ 85006(480) 581-3900(512) 628-3314 Get Directions Write a Review

NPPES record last updated: August 31, 2026. Verified against the NPPES registry weekly; last sync: September 13, 2026.

Record update history: Aug 31, 2026, Jul 21, 2026 (2 updates tracked since 2026).

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About Jacob Robert Blank Do NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

JACOB ROBERT BLANK DO (NPI 1619618907) is an individual student in an organized health care education/training program in Phoenix, Arizona and active in the NPI registry since April 2022. He is enrolled in Medicare PECOS.

NPPES Registry Identity

NPI1619618907

Entity TypeIndividualMale

Primary Taxonomy390200000X

Provider Legal NameJACOB ROBERT BLANKCredential: DO

Location Address775 E WILLETTA STPhoenix, AZ 85006-2723

Mailing Address775 E Willetta StPhoenix, AZ 85006-2723 · (480) 581-3900 · Fax (512) 628-3314

Phone(480) 581-3900

Fax(512) 628-3314

Sole ProprietorNo

Enumeration DateApril 2, 2022

Last NPPES UpdateAugust 31, 20262 updates tracked since enumeration

NPPES CertifiedAugust 31, 2026

✔ NPI 1619618907 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyStudent in an Organized Health Care Education/Training ProgramStudent, Health Care

Taxonomy Code390200000X

Definition

An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.

Also ListedPhysical Medicine & RehabilitationTaxonomy 208100000X · License 012300 (AZ)

775 E WILLETTA ST, Phoenix, AZ 85006

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Jacob Robert Blank Do is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Other Providers at the Same Location NPPES 19

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MR. IVAN SCOTT BUSHMAN RN

Registered Nurse