MEDICARE: JASMINE 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	163WC0200X	Critical Care Medicine Registered Nurse	R235161	MD

General Provider Information

NPI Number	:	1164293783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE BLAKE

Provider Business Mailing Address
First Line	:	2701 MOORES PLAINS BLVD
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-8059
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 MOORES PLAINS BLVD
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-8059
Country	:	US
Telephone Number	:	240-838-8401
Fax Number	:

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

Provider Enumeration Date	:	01/11/2024
Last Update Date	:	01/11/2024

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Directions to “ JASMINE BLAKE ” Practice Location

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