Provider Demographics
NPI:1801822093
Name:JAKOVICH, SOPHIE (OT)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:JAKOVICH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 WASHINGTON ST
Mailing Address - Street 2:APT 202
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4053
Mailing Address - Country:US
Mailing Address - Phone:315-767-8584
Mailing Address - Fax:
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4034
Practice Address - Country:US
Practice Address - Phone:315-785-4088
Practice Address - Fax:315-786-4847
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 11501174400000X
NY009270-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ088DOtherBCBS
FL890272100Medicaid
FLOT 11501OtherOCCUPATIONAL THERAPY