Provider Demographics
NPI:1134903727
Name:BLAKE, JORDAN MARIE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12739 MAPLE BONSAI DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9443
Mailing Address - Country:US
Mailing Address - Phone:941-735-1282
Mailing Address - Fax:
Practice Address - Street 1:1909 HILLBROOKE TRL STE 3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7902
Practice Address - Country:US
Practice Address - Phone:850-299-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst