Provider Demographics
NPI:1730785726
Name:BLAKE, JACK FRANCIS
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:FRANCIS
Last Name:BLAKE
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 1:6225 SMITH AVE STE 1001A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 WEST ST STE 7
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-6010
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst