Provider Demographics
NPI:1285684670
Name:TAKACH, JEFFREY PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:TAKACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-5840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CENTER PLZ
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-9744
Practice Address - Country:US
Practice Address - Phone:732-460-5360
Practice Address - Fax:732-460-7442
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00026700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant