Provider Demographics
NPI:1912610866
Name:BLAKE, JILLISA YVETTE (CDCA)
Entity type:Individual
Prefix:
First Name:JILLISA
Middle Name:YVETTE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 VENETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1855
Mailing Address - Country:US
Mailing Address - Phone:614-956-9323
Mailing Address - Fax:
Practice Address - Street 1:819 VENETIAN WAY
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1855
Practice Address - Country:US
Practice Address - Phone:614-956-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182979101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)