=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891952370
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARIE BLAKE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2008
-----------------------------------------------------
Last Update Date | 01/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 BEAUBIEN ST CHILDRENS HOSPITAL OF MI 4TH FL
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-745-5484
-----------------------------------------------------
Fax | 313-966-2423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 SAINT ANTOINE ST UHC 5D - MAILBOX 226 UNIVERSITY PEDIATRICIANS
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-745-4405
-----------------------------------------------------
Fax | 313-966-0665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | 4301090782
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------