Provider Demographics
NPI:1043948862
Name:YAMASAKI, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:YAMASAKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12521 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8454
Mailing Address - Country:US
Mailing Address - Phone:805-448-3072
Mailing Address - Fax:
Practice Address - Street 1:3921 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1801
Practice Address - Country:US
Practice Address - Phone:602-764-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ270211163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool