Provider Demographics
NPI:1790555837
Name:FLAKE, JOEL AMMON (IS)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:AMMON
Last Name:FLAKE
Suffix:
Gender:M
Credentials:IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 N LARCHMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6095
Mailing Address - Country:US
Mailing Address - Phone:208-781-2287
Mailing Address - Fax:
Practice Address - Street 1:2702 N LARCHMONT AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6095
Practice Address - Country:US
Practice Address - Phone:208-781-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician