Healthcare Provider Details

I. General information

NPI: 1891952370
Provider Name (Legal Business Name): JENNIFER MARIE BLAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST CHILDRENS HOSPITAL OF MI 4TH FL
DETROIT MI
48201-2119
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST UHC 5D - MAILBOX 226 UNIVERSITY PEDIATRICIANS
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5484
  • Fax: 313-966-2423
Mailing address:
  • Phone: 313-745-4405
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301090782
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: