Healthcare Provider Details

I. General information

NPI: 1215810221
Provider Name (Legal Business Name): JASMINE BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 MEDA ST
MEMPHIS TN
38104-5817
US

IV. Provider business mailing address

997 MEDA ST
MEMPHIS TN
38104-5817
US

V. Phone/Fax

Practice location:
  • Phone: 479-800-8311
  • Fax:
Mailing address:
  • Phone: 479-800-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: