Provider Demographics
NPI:1851113724
Name:BLANK, JACOB MICHAEL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:BLANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 KENYON DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-1625
Mailing Address - Country:US
Mailing Address - Phone:215-816-1395
Mailing Address - Fax:
Practice Address - Street 1:32841 MIDDLEBELT RD STE 403
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1714
Practice Address - Country:US
Practice Address - Phone:248-851-7739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352001031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical