Provider Demographics
NPI:1407834781
Name:BLAKE, JEFFREY LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4410
Mailing Address - Country:US
Mailing Address - Phone:310-392-7889
Mailing Address - Fax:310-314-4431
Practice Address - Street 1:1714 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4410
Practice Address - Country:US
Practice Address - Phone:310-392-7889
Practice Address - Fax:310-314-4431
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05281ZOtherBLUE SHIELD OF CA
CAS37419Medicare UPIN
CAWPT17676CMedicare ID - Type Unspecified
CAWPT17676BMedicare ID - Type Unspecified