Provider Demographics
NPI:1598073835
Name:BLAKE, JENNIFER MARIE (MS, ACNP-BC, CNRN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS, ACNP-BC, CNRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W 38TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1167
Mailing Address - Country:US
Mailing Address - Phone:512-306-1323
Mailing Address - Fax:
Practice Address - Street 1:601 E 15TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1930
Practice Address - Country:US
Practice Address - Phone:512-324-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704258847163WN0800X, 363LA2100X
TX795600363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience