Provider Demographics
NPI:1801574074
Name:BLAKE, JENNIFER HESS (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HESS
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13422 STONE DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4557
Mailing Address - Country:US
Mailing Address - Phone:276-701-0030
Mailing Address - Fax:
Practice Address - Street 1:1114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-5014
Practice Address - Country:US
Practice Address - Phone:276-701-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
VA0701012644101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty