Provider Demographics
NPI:1154486769
Name:BLAKE, JACOB L (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5590 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3019
Mailing Address - Country:US
Mailing Address - Phone:775-323-2080
Mailing Address - Fax:775-323-8216
Practice Address - Street 1:5590 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3019
Practice Address - Country:US
Practice Address - Phone:775-323-2080
Practice Address - Fax:775-683-9404
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14407207L00000X, 207LP2900X
CAA95206207L00000X, 207LP2900X
WAMD60071790207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGM170ZMedicare PIN