Provider Demographics
NPI:1225537269
Name:BLAKE, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
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 1:100 SUGAR AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COMMUNITY ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5201
Practice Address - Country:US
Practice Address - Phone:304-242-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV$$$$$$$$$Medicaid