Provider Demographics
NPI:1043881220
Name:HAKE, JONATHAN (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HAKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11599 SPRUCEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8436
Mailing Address - Country:US
Mailing Address - Phone:618-973-5826
Mailing Address - Fax:
Practice Address - Street 1:11007 RADCLIFF DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9521
Practice Address - Country:US
Practice Address - Phone:616-895-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005649225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant