MEDICARE: BLAKE HOME HEALTH AGENCY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	1999	VA

General Provider Information

NPI Number	:	1952751059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE HOME HEALTH AGENCY

Provider Business Mailing Address
First Line	:	5709 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-4420
Country	:	US
Telephone Number	:	804-545-1974
Fax Number	:	888-314-9510

Provider Business Practice Location Address
First Line	:	5709 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-4420
Country	:	US
Telephone Number	:	804-545-1974
Fax Number	:	888-314-9510

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. DIONNE JACKSON
Credential	:	QMHP
Telephone Number	:	804-545-1974

Provider Enumeration Date	:	06/20/2016
Last Update Date	:	08/14/2019

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Directions to “BLAKE HOME HEALTH AGENCY ” Practice Location

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