Provider Demographics
NPI:1740843853
Name:DENNISON, JAKE ELIJAH
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ELIJAH
Last Name:DENNISON
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 1:18686 LEMON ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-5324
Mailing Address - Country:US
Mailing Address - Phone:760-680-1944
Mailing Address - Fax:
Practice Address - Street 1:610 BERCUT DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0115
Practice Address - Country:US
Practice Address - Phone:760-680-1944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXEP905816521OtherBLUE SHIELD