Provider Demographics
NPI:1134740301
Name:STEPHEN, JAKE (DO)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:STEPHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E EISENHOWER PKWY
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-3364
Mailing Address - Country:US
Mailing Address - Phone:734-615-7246
Mailing Address - Fax:734-936-6585
Practice Address - Street 1:325 E EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3364
Practice Address - Country:US
Practice Address - Phone:734-615-7246
Practice Address - Fax:734-936-6585
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019842207R00000X
MI51010278302081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine