Provider Demographics
NPI:1114792280
Name:BLAKE, JILLIAN MARIE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:BLAKE
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 1:156 CHESTER RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-5555
Mailing Address - Country:US
Mailing Address - Phone:603-204-4208
Mailing Address - Fax:
Practice Address - Street 1:156 CHESTER RD
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-5555
Practice Address - Country:US
Practice Address - Phone:603-204-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANA363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care