Provider Demographics
NPI:1558085670
Name:BLAKE, JENNIFER L (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:CASTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:5009 POINTCLEAR CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1963
Mailing Address - Country:US
Mailing Address - Phone:469-585-5551
Mailing Address - Fax:
Practice Address - Street 1:2501 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5824
Practice Address - Country:US
Practice Address - Phone:817-924-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical