Provider Demographics
NPI:1346809456
Name:FORRESTER, JAKE WYATT (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:WYATT
Last Name:FORRESTER
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 9TH AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-3645
Mailing Address - Country:US
Mailing Address - Phone:864-386-3767
Mailing Address - Fax:
Practice Address - Street 1:649 9TH AVE APT 2A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-3645
Practice Address - Country:US
Practice Address - Phone:864-386-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY743979-1163WC0200X
390200000X
NY743979367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program