Basic Information
| Provider Information | |||||||||
| NPI: | 1477063899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 368 FELL ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941025144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158610828 | ||||||||
| FaxNumber: | 4158610257 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 TARAVAL ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157523416 | ||||||||
| FaxNumber: | 4157523483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.