Provider Demographics
NPI:1376322560
Name:JAKE, AYANNA (MT)
Entity Type:Individual
Prefix:
First Name:AYANNA
Middle Name:
Last Name:JAKE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 DUNBARTON DR STE H
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5016
Mailing Address - Country:US
Mailing Address - Phone:769-226-1925
Mailing Address - Fax:
Practice Address - Street 1:2084 DUNBARTON DR STE H
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5016
Practice Address - Country:US
Practice Address - Phone:769-226-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist