Provider Demographics
NPI:1447601133
Name:BLAKE, JILL (IADC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-3203
Mailing Address - Country:US
Mailing Address - Phone:712-226-1801
Mailing Address - Fax:712-293-4804
Practice Address - Street 1:3500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51103-3203
Practice Address - Country:US
Practice Address - Phone:712-226-1801
Practice Address - Fax:712-293-4804
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)