Healthcare Provider Details

I. General information

NPI: 1629998232
Provider Name (Legal Business Name): BLAKE TRAVERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 UNION UNIVERSITY DR
JACKSON TN
38305-3697
US

IV. Provider business mailing address

1027 US HIGHWAY 60 W
SMITHLAND KY
42081-8942
US

V. Phone/Fax

Practice location:
  • Phone: 270-508-0552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberI17135
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: