Provider Demographics
NPI:1619284742
Name:BLAKE, JAY L (NP)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 FIFTH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3107
Mailing Address - Country:US
Mailing Address - Phone:619-542-2483
Mailing Address - Fax:
Practice Address - Street 1:3965 FIFTH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3107
Practice Address - Country:US
Practice Address - Phone:619-542-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2265898363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner