Provider Demographics
NPI:1780138214
Name:BLAKE, JACKLYN MICHELE (LCMHC, MBA)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MICHELE
Last Name:BLAKE
Suffix:
Gender:
Credentials:LCMHC, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NEW WAVERLY PL STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7404
Mailing Address - Country:US
Mailing Address - Phone:919-889-4448
Mailing Address - Fax:
Practice Address - Street 1:600 NEW WAVERLY PL STE 100
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7404
Practice Address - Country:US
Practice Address - Phone:984-268-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15965101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health