Provider Demographics
NPI:1114792280
Name:BLAKE, JILLIAN MARIE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
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 1:12 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2865
Mailing Address - Country:US
Mailing Address - Phone:603-204-4208
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANA363LA2100X
MARN2326798363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care