Provider Demographics
NPI:1952818304
Name:JUSTICE, JAKE THOMAS
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:THOMAS
Last Name:JUSTICE
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 1:1A SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILLS RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28759-9688
Mailing Address - Country:US
Mailing Address - Phone:828-290-4102
Mailing Address - Fax:
Practice Address - Street 1:3971 LITTLE SAVANNAH ROAD
Practice Address - Street 2:
Practice Address - City:CULLOWHEE
Practice Address - State:NC
Practice Address - Zip Code:28723
Practice Address - Country:US
Practice Address - Phone:828-227-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program