Provider Demographics
NPI:1639300742
Name:MCCLOSKEY, JAKE O
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:O
Last Name:MCCLOSKEY
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 1:920 S 25 E
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-4176
Mailing Address - Country:US
Mailing Address - Phone:435-704-1661
Mailing Address - Fax:
Practice Address - Street 1:170 E ALTAMIRA DR
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3509
Practice Address - Country:US
Practice Address - Phone:435-586-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT171M00000XMedicaid