MEDICARE: MR. JORDEN DENEIL BLAKELY OWNER

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	376J00000X	Homemaker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	92-0390919	OTHER	OH	HOMECARE

General Provider Information

NPI Number	:	1568171833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORDEN DENEIL BLAKELY OWNER

Provider Business Mailing Address
First Line	:	6805 MAYFIELD RD APT 606
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2252
Country	:	US
Telephone Number	:	216-801-5494
Fax Number	:

Provider Business Practice Location Address
First Line	:	6805 MAYFIELD RD APT 606
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2252
Country	:	US
Telephone Number	:	216-801-5494
Fax Number	:

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

Provider Enumeration Date	:	11/16/2022
Last Update Date	:	04/08/2025

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