Provider Demographics
NPI:1477737435
Name:TAKA, JALDEZA
Entity Type:Individual
Prefix:
First Name:JALDEZA
Middle Name:
Last Name:TAKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BUTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-3116
Mailing Address - Country:US
Mailing Address - Phone:978-821-1028
Mailing Address - Fax:
Practice Address - Street 1:2 BUTTONWOOD LN
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-3116
Practice Address - Country:US
Practice Address - Phone:978-821-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9454225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS31418226OtherDRIVER'S LICENSE