Provider Demographics
NPI:1801103197
Name:FRATKIN, JAKE PAUL (OMD, LAC)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:PAUL
Last Name:FRATKIN
Suffix:
Gender:M
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7764 JADE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-3225
Mailing Address - Country:US
Mailing Address - Phone:303-554-0722
Mailing Address - Fax:303-554-0299
Practice Address - Street 1:7764 JADE CT
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3225
Practice Address - Country:US
Practice Address - Phone:303-554-0722
Practice Address - Fax:303-554-0299
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO162171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist