Provider Demographics
NPI:1013779594
Name:COLAVITO, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:COLAVITO
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 1:276 GLEN ST APT 306
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3963
Mailing Address - Country:US
Mailing Address - Phone:518-858-1032
Mailing Address - Fax:
Practice Address - Street 1:276 GLEN ST APT 306
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3963
Practice Address - Country:US
Practice Address - Phone:518-858-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician