MEDICARE: JORDAN MARIE BLAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1134903727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN MARIE BLAKE

Provider Business Mailing Address
First Line	:	1500 S DOUGLAS RD STE 230
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-4108
Country	:	US
Telephone Number	:	844-244-1818
Fax Number	:

Provider Business Practice Location Address
First Line	:	10817 BLOOMINGDALE AVE
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578-3616
Country	:	US
Telephone Number	:	813-336-3529
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	05/04/2026

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