Healthcare Provider Details

I. General information

NPI: 1447898887
Provider Name (Legal Business Name): JESSICA ROSE BLAKE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAHC VICENZA
APO AE
09630
US

IV. Provider business mailing address

CMR 427 BOX 1085
APO AE
09630-0011
US

V. Phone/Fax

Practice location:
  • Phone: 349-711-5604
  • Fax:
Mailing address:
  • Phone: 349-711-5604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305212810
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: