Provider Demographics
NPI:1679221576
Name:OTJEN, JAKE M
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:M
Last Name:OTJEN
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 1:41769 ENTERPRISE CIR N STE A-101
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5626
Mailing Address - Country:US
Mailing Address - Phone:951-719-3738
Mailing Address - Fax:951-719-3731
Practice Address - Street 1:41769 ENTERPRISE CIR N STE A-101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5626
Practice Address - Country:US
Practice Address - Phone:951-719-3738
Practice Address - Fax:951-719-3731
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-206080106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician