Provider Demographics
NPI:1699940221
Name:BLAKE, JESSICA NICOLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:19670 STATE ROAD 120
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-9131
Mailing Address - Country:US
Mailing Address - Phone:574-294-6197
Mailing Address - Fax:574-296-9158
Practice Address - Street 1:19670 STATE ROAD 120
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:IN
Practice Address - Zip Code:46507-9131
Practice Address - Country:US
Practice Address - Phone:574-294-6197
Practice Address - Fax:574-296-9158
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004183A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist