Healthcare Provider Details

I. General information

NPI: 1437080397
Provider Name (Legal Business Name): MRS. JAMIE LEANN BLAKELEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 AZTALAN STREET
JOHNSON CREEK WI
53038
US

IV. Provider business mailing address

PO BOX 39
JOHNSON CREEK WI
53038-0039
US

V. Phone/Fax

Practice location:
  • Phone: 920-541-4800
  • Fax:
Mailing address:
  • Phone: 920-541-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1590039794
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: