Healthcare Provider Details

I. General information

NPI: 1114839719
Provider Name (Legal Business Name): JAY BLAKEMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S 4TH ST APT 307
LANDER WY
82520-3131
US

IV. Provider business mailing address

203 S 4TH ST APT 307
LANDER WY
82520-3131
US

V. Phone/Fax

Practice location:
  • Phone: 307-349-7080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: