Provider Demographics
NPI:1770351769
Name:PICKENS, JAKE (CRNP)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PICKENS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:HALEYVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35565-1506
Mailing Address - Country:US
Mailing Address - Phone:205-485-7822
Mailing Address - Fax:833-449-4072
Practice Address - Street 1:1728 11TH AVE
Practice Address - Street 2:
Practice Address - City:HALEYVILLE
Practice Address - State:AL
Practice Address - Zip Code:35565-1506
Practice Address - Country:US
Practice Address - Phone:205-485-7822
Practice Address - Fax:833-449-4072
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-170309163WE0003X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency