Provider Demographics
NPI:1821813809
Name:BLAKE, JONATHAN THOMAS
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:THOMAS
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7160 RAFAEL RIVERA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-5393
Mailing Address - Country:US
Mailing Address - Phone:702-850-2691
Mailing Address - Fax:
Practice Address - Street 1:7160 RAFAEL RIVERA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-5393
Practice Address - Country:US
Practice Address - Phone:702-850-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician