=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154108439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN T BLAKE LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2023
-----------------------------------------------------
Last Update Date | 09/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 WILLOW AVE
-----------------------------------------------------
City | OLYPHANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18447-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-382-8157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 CHURCH ST
-----------------------------------------------------
City | DUNMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18512-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-878-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW137924
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------