Provider Demographics
NPI:1770957821
Name:CARTER, JAKE JOSEPH
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:JOSEPH
Last Name:CARTER
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 1:1712 N GREENFIELD CIR NE
Mailing Address - Street 2:APT 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5675
Mailing Address - Country:US
Mailing Address - Phone:616-502-3881
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-456-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor