Provider Demographics
NPI:1750020913
Name:HAN, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:HAN
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 1:2623 MIDWAY BRANCH DR APT 202
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-4131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8600 SNOWDEN RIVER PKWY STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1983
Practice Address - Country:US
Practice Address - Phone:410-720-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5484225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant