Provider Demographics
NPI:1568171833
Name:BLAKELY, JORDEN DENEIL (OWNER)
Entity Type:Individual
Prefix:MR
First Name:JORDEN
Middle Name:DENEIL
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:MR
Other - First Name:JORDEN
Other - Middle Name:DENEIL
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6805 MAYFIELD RD APT 606
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2252
Mailing Address - Country:US
Mailing Address - Phone:216-801-5494
Mailing Address - Fax:
Practice Address - Street 1:6805 MAYFIELD RD APT 606
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2252
Practice Address - Country:US
Practice Address - Phone:216-801-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH92-0390919OtherHOMECARE