Provider Demographics
NPI:1194212548
Name:BLAKE, JEANETTE L (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-2232
Mailing Address - Country:US
Mailing Address - Phone:804-261-5085
Mailing Address - Fax:
Practice Address - Street 1:2204 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-2232
Practice Address - Country:US
Practice Address - Phone:804-261-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool