Provider Demographics
NPI:1083337851
Name:BLAKELY, JESSIE QUEEN (MS)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:QUEEN
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14630 BROADGREEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-6426
Mailing Address - Country:US
Mailing Address - Phone:225-773-1160
Mailing Address - Fax:
Practice Address - Street 1:5225 KATY FWY STE 103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-2263
Practice Address - Country:US
Practice Address - Phone:832-225-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health