Provider Demographics
NPI:1386799070
Name:BLAKE, JACQUELINE MARGARET (MA, LPC, LLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARGARET
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA, LPC, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2244
Mailing Address - Country:US
Mailing Address - Phone:248-858-7766
Mailing Address - Fax:248-858-7201
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:248-858-7201
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009441103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid