Healthcare Provider Details

I. General information

NPI: 1497245708
Provider Name (Legal Business Name): JENNIFER CHRISTINA BLAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 8TH AVE STE 306
FORT WORTH TX
76104-2602
US

IV. Provider business mailing address

800 8TH AVE STE 306
FORT WORTH TX
76104-2602
US

V. Phone/Fax

Practice location:
  • Phone: 682-224-3748
  • Fax: 682-841-0039
Mailing address:
  • Phone: 682-224-3748
  • Fax: 682-841-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberU4745
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: