Provider Demographics
NPI:1760009062
Name:HERNANDEZ, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:HERNANDEZ
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 1:442 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-2794
Mailing Address - Country:US
Mailing Address - Phone:929-295-7822
Mailing Address - Fax:929-202-2629
Practice Address - Street 1:442 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-2794
Practice Address - Country:US
Practice Address - Phone:929-295-7822
Practice Address - Fax:929-202-2629
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY732427163WP0808X
FL11014943363LP0808X
NY403679363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty