Provider Demographics
NPI:1356932024
Name:BACKEN, JAKE EVERETT (RVT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:EVERETT
Last Name:BACKEN
Suffix:
Gender:M
Credentials:RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W LYNWOOD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2239
Mailing Address - Country:US
Mailing Address - Phone:541-680-2858
Mailing Address - Fax:
Practice Address - Street 1:415 W LYNWOOD AVE APT 2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2239
Practice Address - Country:US
Practice Address - Phone:541-680-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1934022471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty