Provider Demographics
NPI:1821320193
Name:BLAKE, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1269 EAST 223 RD STREET
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-5081
Mailing Address - Country:US
Mailing Address - Phone:917-548-4707
Mailing Address - Fax:
Practice Address - Street 1:1809 NOSTRAND AVENUE
Practice Address - Street 2:2 ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7181
Practice Address - Country:US
Practice Address - Phone:718-421-4224
Practice Address - Fax:718-421-4774
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH506269163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386450Medicaid