Provider Demographics
NPI:1073704771
Name:JAKE, TEHNIJAH L
Entity Type:Individual
Prefix:
First Name:TEHNIJAH
Middle Name:L
Last Name:JAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7707
Practice Address - Street 1:NAVAJO ROUTE 12 & 64
Practice Address - Street 2:
Practice Address - City:TSAILE
Practice Address - State:AZ
Practice Address - Zip Code:86556
Practice Address - Country:US
Practice Address - Phone:928-724-3714
Practice Address - Fax:928-724-3791
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-112021041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator