Provider Demographics
NPI:1477063899
Name:BLAIR, JACOB RYAN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4523
Mailing Address - Country:US
Mailing Address - Phone:415-474-7310
Mailing Address - Fax:415-922-9418
Practice Address - Street 1:1500 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4523
Practice Address - Country:US
Practice Address - Phone:415-605-5028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116725104100000X
172V00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker