Provider Demographics
NPI:1689321101
Name:DEJONG, BLAKE R
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:R
Last Name:DEJONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14675 MARTIN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2016
Mailing Address - Country:US
Mailing Address - Phone:952-797-3045
Mailing Address - Fax:
Practice Address - Street 1:14675 MARTIN DR STE 100
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-2016
Practice Address - Country:US
Practice Address - Phone:952-797-3045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty