Individual
JAREN H. BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
777 N 500 W STE 101A, PROVO, UT 84601-1594
(385) 375-7989
Mailing address
3214 N UNIVERSITY AVE # 116, PROVO, UT 84604-4405
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
14222
NV
207Q00000X
Family Medicine Physician
Primary
8115390-1205
UT
207Q00000X
Family Medicine Physician
M-9562
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010157782
REGENCE BLUE SHIELD
ID
01
—
291778
ALTIUS OLD
ID
01
—
313147
ALTIUS
ID
01
—
76744
BLUE CROSS OLD
ID
01
—
76965
BLUE CROSS
ID
05
—
807555200
—
ID
Enumeration date
07/16/2006
Last updated
08/24/2022
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