Provider Demographics
NPI:1346727997
Name:BLAKE, CHRISJON AUGUSTUS
Entity type:Individual
Prefix:
First Name:CHRISJON
Middle Name:AUGUSTUS
Last Name:BLAKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 HOTEL CIR N STE 314
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2803
Mailing Address - Country:US
Mailing Address - Phone:619-961-2120
Mailing Address - Fax:
Practice Address - Street 1:1660 HOTEL CIR N STE 314
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2803
Practice Address - Country:US
Practice Address - Phone:619-961-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
AZRBT-18-60640106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty