Provider Demographics
NPI:1285023242
Name:WAYNE, JAKE (MS)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:WAYNE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 FERN ST
Mailing Address - Street 2:
Mailing Address - City:YEADON
Mailing Address - State:PA
Mailing Address - Zip Code:19050-3225
Mailing Address - Country:US
Mailing Address - Phone:610-623-0715
Mailing Address - Fax:
Practice Address - Street 1:529 FERN ST
Practice Address - Street 2:
Practice Address - City:YEADON
Practice Address - State:PA
Practice Address - Zip Code:19050-3225
Practice Address - Country:US
Practice Address - Phone:610-623-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health