Provider Demographics
NPI:1558763532
Name:KMAK, JAMAE' (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:JAMAE'
Middle Name:
Last Name:KMAK
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:JAMAE'
Other - Middle Name:
Other - Last Name:VAN EEUWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 E CORAL GABLES DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3690
Mailing Address - Country:US
Mailing Address - Phone:602-290-4880
Mailing Address - Fax:
Practice Address - Street 1:17300 N 88TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3501
Practice Address - Country:US
Practice Address - Phone:602-290-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-21
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5945252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency