Provider Demographics
NPI:1508018896
Name:BLAKE, JILL ANN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:109 DUFFY DRIVE
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-0082
Mailing Address - Country:US
Mailing Address - Phone:304-253-7408
Mailing Address - Fax:
Practice Address - Street 1:3771 ROBERT C. BYRD DRIVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-5710
Practice Address - Fax:304-255-5702
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV45615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily