Provider Demographics
NPI:1710428388
Name:BLASE, JESSYCA (LLMSW)
Entity Type:Individual
Prefix:
First Name:JESSYCA
Middle Name:
Last Name:BLASE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S LIVERNOIS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2585
Mailing Address - Country:US
Mailing Address - Phone:248-608-8800
Mailing Address - Fax:248-608-2490
Practice Address - Street 1:441 S LIVERNOIS RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2585
Practice Address - Country:US
Practice Address - Phone:248-608-8800
Practice Address - Fax:248-608-2490
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician