=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174237374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE BLAKE-JONES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9455 STONE VIEW DR NE # DE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-916-0310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9455 STONE VIEW DR NE # DE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-916-0310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------