Provider Demographics
NPI:1770671018
Name:BLAKE, JEREMY T (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:T
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 COATSLAND DR.
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301
Mailing Address - Country:US
Mailing Address - Phone:731-423-1500
Mailing Address - Fax:731-423-0342
Practice Address - Street 1:264 COATSLAND DR.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-423-1500
Practice Address - Fax:731-423-0342
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000031623208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440909Medicaid
TN5440909Medicaid