Provider Demographics
NPI:1902282684
Name:BLAKE, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:2-217E.01
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4512
Mailing Address - Country:US
Mailing Address - Phone:703-207-6976
Mailing Address - Fax:703-653-7008
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:2-217E.01
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-207-6976
Practice Address - Fax:703-653-7008
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040090331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical