Provider Demographics
NPI:1093108540
Name:HAKE, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:HAKE
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 1:1360 LIGHTHOUSE PT
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034-9419
Mailing Address - Country:US
Mailing Address - Phone:260-229-7170
Mailing Address - Fax:
Practice Address - Street 1:5610 E MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-5815
Practice Address - Country:US
Practice Address - Phone:260-229-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001327A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant