Organization
EAST TEXAS FAMILY SUPPORT CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER A BLAKE (OWNER)
(954) 557-2775
Entity
Organization
Contact information
Practice address
1305 DOCTORS DR, TYLER, TX 75701-2263
(903) 525-9397
(903) 525-9398
Mailing address
1305 DOCTORS DR, TYLER, TX 75701-2263
(903) 525-9397
(903) 525-9398
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
—
—
261QM2500X
Medical Specialty Clinic/Center
—
—
261QP3300X
Pain Clinic/Center
Primary
—
—
Other
Enumeration date
01/09/2020
Last updated
06/11/2020
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