Provider Demographics
NPI:1477178291
Name:BAKER, MARK JON
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JON
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAN BRUNO AVE UNIT G
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-1505
Mailing Address - Country:US
Mailing Address - Phone:407-491-6562
Mailing Address - Fax:
Practice Address - Street 1:1 SAN BRUNO AVE UNIT G
Practice Address - Street 2:
Practice Address - City:BRISBANE
Practice Address - State:CA
Practice Address - Zip Code:94005-1505
Practice Address - Country:US
Practice Address - Phone:407-491-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2797224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant