Provider Demographics
NPI:1366942245
Name:BLAKE, JASMINE DARE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JASMINE
Middle Name:DARE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:JASMINE
Other - Middle Name:DARE
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1975 W ELK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3787
Mailing Address - Country:US
Mailing Address - Phone:423-543-0073
Mailing Address - Fax:423-543-1277
Practice Address - Street 1:1975 W ELK AVE STE 1
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3787
Practice Address - Country:US
Practice Address - Phone:423-543-0073
Practice Address - Fax:423-543-1277
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist