Provider Demographics
NPI:1063750594
Name:BLAKELY, JACQUELINE (ND, CRC, LAC)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:ND, CRC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-2810
Mailing Address - Country:US
Mailing Address - Phone:415-643-6600
Mailing Address - Fax:415-643-6644
Practice Address - Street 1:1615 20TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-2810
Practice Address - Country:US
Practice Address - Phone:415-643-6600
Practice Address - Fax:415-643-6644
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND 573175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath