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General NPI Number Information
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NPI Number | 1851113724
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Entity Type | Individual
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Provider Name | JACOB MICHAEL BLANK
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Gender | Male
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Dates
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Enumeration Date | 10/30/2024
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 32841 MIDDLEBELT RD STE 403
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-1714
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Country | US
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Telephone | 248-851-7739
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Fax |
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Provider Business Mailing Address
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Address Line | 1085 KENYON DR
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City | FORT WASHINGTON
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State | PA
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Zip | 19034-1625
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Country | US
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Telephone | 215-816-1395
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6352001031
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License Number State | MI
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