Provider Demographics
NPI:1174012553
Name:BLAKE, JEANNE MARIE
Entity Type:Individual
Prefix:
First Name:JEANNE
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 1:6631 EASTWOOD ACRES RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-6111
Mailing Address - Country:US
Mailing Address - Phone:239-738-6972
Mailing Address - Fax:
Practice Address - Street 1:999 TRAIL TERRACE DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2329
Practice Address - Country:US
Practice Address - Phone:239-649-2222
Practice Address - Fax:239-649-0522
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23109225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant