Provider Demographics
NPI:1215810221
Name:BLAKE, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:997 MEDA ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5817
Mailing Address - Country:US
Mailing Address - Phone:479-800-8311
Mailing Address - Fax:
Practice Address - Street 1:997 MEDA ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5817
Practice Address - Country:US
Practice Address - Phone:479-800-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool