Provider Demographics
NPI:1457649204
Name:BLAKE, JENNIFER L (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11630 SE 40TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6195
Mailing Address - Country:US
Mailing Address - Phone:503-794-5968
Mailing Address - Fax:
Practice Address - Street 1:11630 SE 40TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6195
Practice Address - Country:US
Practice Address - Phone:503-794-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR1530101Y00000X
ORR1576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor