Provider Demographics
NPI:1720786890
Name:COY, JAKE SCOTT
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:SCOTT
Last Name:COY
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 1:4572 MEGA ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7098
Mailing Address - Country:US
Mailing Address - Phone:330-305-0337
Mailing Address - Fax:330-305-0437
Practice Address - Street 1:4572 MEGA ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7098
Practice Address - Country:US
Practice Address - Phone:330-305-0337
Practice Address - Fax:330-305-0437
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician