Provider Demographics
NPI:1841217858
Name:BLAKE, JAREN H (MD)
Entity Type:Individual
Prefix:
First Name:JAREN
Middle Name:H
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 1:3214 N UNIVERSITY AVE # 116
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 N 500 W STE 101A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1594
Practice Address - Country:US
Practice Address - Phone:385-375-7989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9562207Q00000X
UT8115390-1205207Q00000X
NV14222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID291778OtherALTIUS OLD
ID76744OtherBLUE CROSS OLD
ID76965OtherBLUE CROSS
ID000010157782OtherREGENCE BLUE SHIELD
ID313147OtherALTIUS
ID807555200Medicaid
I66323Medicare UPIN
ID113426511Medicare PIN
ID000010157782OtherREGENCE BLUE SHIELD
ID76744OtherBLUE CROSS OLD