Provider Demographics
NPI:1346838836
Name:BLAKE, JACQUELYN (MED)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-1011
Mailing Address - Country:US
Mailing Address - Phone:781-264-7954
Mailing Address - Fax:
Practice Address - Street 1:61 ELM ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-1011
Practice Address - Country:US
Practice Address - Phone:781-264-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty