Provider Demographics
NPI:1982998282
Name:BLAKE, JENNIFER LYNN (MSPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 PLAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-2744
Mailing Address - Country:US
Mailing Address - Phone:781-319-0024
Mailing Address - Fax:781-319-0088
Practice Address - Street 1:506 PLAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MARSHFIELD
Practice Address - State:MA
Practice Address - Zip Code:02050-2744
Practice Address - Country:US
Practice Address - Phone:781-319-0024
Practice Address - Fax:781-319-0088
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist