Provider Demographics
NPI:1225734130
Name:BLAKE, JESSAMIN SHAYLYN
Entity Type:Individual
Prefix:
First Name:JESSAMIN
Middle Name:SHAYLYN
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 1:189 N HARPER ST
Mailing Address - Street 2:
Mailing Address - City:NELSONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45764-1592
Mailing Address - Country:US
Mailing Address - Phone:740-856-7684
Mailing Address - Fax:
Practice Address - Street 1:189 N HARPER ST
Practice Address - Street 2:
Practice Address - City:NELSONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45764-1592
Practice Address - Country:US
Practice Address - Phone:740-856-7684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health