Provider Demographics
NPI:1821501602
Name:BLAKE, JESSICA (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1701
Mailing Address - Country:US
Mailing Address - Phone:618-346-6213
Mailing Address - Fax:
Practice Address - Street 1:9000 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-1701
Practice Address - Country:US
Practice Address - Phone:618-346-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist