Provider Demographics
NPI:1235485699
Name:BLAKE, JILL K (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:K
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:K
Other - Last Name:SANTAMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW-CC
Mailing Address - Street 1:50 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1536
Mailing Address - Country:US
Mailing Address - Phone:800-434-3000
Mailing Address - Fax:
Practice Address - Street 1:50 MOODY ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1536
Practice Address - Country:US
Practice Address - Phone:800-434-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC136211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical