Basic Information
| Provider Information | |||||||||
| NPI: | 1154839637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACOB BLAKE, MD LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIERRA PEAK PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5590 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895113019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5590 KIETZKE LANE | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
| FaxNumber: | 7753238216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | QUINLAN | ||||||||
| AuthorizedOfficialFirstName: | KENDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7757201573 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 11407 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.