Healthcare Provider Details

I. General information

NPI: 1972620110
Provider Name (Legal Business Name): JENNIFER KAY BLAKE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SHELTON MCMURPHEY BLVD STE 101
EUGENE OR
97401-5015
US

IV. Provider business mailing address

3995 MARCOLA RD
SPRINGFIELD OR
97477-7948
US

V. Phone/Fax

Practice location:
  • Phone: 541-210-8090
  • Fax: 541-210-5310
Mailing address:
  • Phone: 541-726-1465
  • Fax: 541-726-5085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC5663
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500663059
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier1972620110
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNPI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: