Provider Demographics
NPI:1952893422
Name:BLAKELY, JARRED LAVELL
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:LAVELL
Last Name:BLAKELY
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 1:718 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-3213
Mailing Address - Country:US
Mailing Address - Phone:209-453-6903
Mailing Address - Fax:
Practice Address - Street 1:718 E 7TH ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-3213
Practice Address - Country:US
Practice Address - Phone:209-453-6903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5439106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5439OtherLEARNING ARTS