Provider Demographics
NPI:1154108439
Name:BLAKE, JONATHAN T (LSW)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:T
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-1907
Mailing Address - Country:US
Mailing Address - Phone:570-878-5008
Mailing Address - Fax:
Practice Address - Street 1:126 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1442
Practice Address - Country:US
Practice Address - Phone:570-382-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137924104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty