Provider Demographics
NPI:1073260311
Name:WOOD, JAKE A
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:A
Last Name:WOOD
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 1:9233 E NEVILLE AVE UNIT 1099
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-1510
Mailing Address - Country:US
Mailing Address - Phone:801-369-8569
Mailing Address - Fax:
Practice Address - Street 1:5800 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3702
Practice Address - Country:US
Practice Address - Phone:801-369-8569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program