Healthcare Provider Details

I. General information

NPI: 1346727997
Provider Name (Legal Business Name): CHRISJON AUGUSTUS BLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 HOTEL CIR N STE 314
SAN DIEGO CA
92108-2803
US

IV. Provider business mailing address

1660 HOTEL CIR N STE 314
SAN DIEGO CA
92108-2803
US

V. Phone/Fax

Practice location:
  • Phone: 619-961-2120
  • Fax:
Mailing address:
  • Phone: 619-961-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-60640
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: