Provider Demographics
NPI:1811687700
Name:BLAKE-HOLDEN, JENNIFER HAIDENTHALLER (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAIDENTHALLER
Last Name:BLAKE-HOLDEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7916 HANNA AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4721
Mailing Address - Country:US
Mailing Address - Phone:818-448-0336
Mailing Address - Fax:
Practice Address - Street 1:7916 HANNA AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-4721
Practice Address - Country:US
Practice Address - Phone:818-448-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19731171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist