Provider Demographics
NPI:1881197234
Name:BLAKE, JENNIFER MICHELLE (LPCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13022
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3022
Mailing Address - Country:US
Mailing Address - Phone:575-888-7437
Mailing Address - Fax:575-233-6324
Practice Address - Street 1:1800 AVENIDA DE MESILLA STE D
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3920
Practice Address - Country:US
Practice Address - Phone:575-888-7467
Practice Address - Fax:575-233-6324
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0183431101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor