Provider Demographics
NPI:1154644136
Name:BLAKE, JODIE MEGAN (PT)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:MEGAN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 BURTON ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2444
Mailing Address - Country:US
Mailing Address - Phone:616-974-4466
Mailing Address - Fax:616-974-4582
Practice Address - Street 1:4069 LAKE DR SE
Practice Address - Street 2:SUITE 114
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-726-8365
Practice Address - Fax:616-726-8364
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16150248Medicare PIN