Provider Demographics
NPI:1841037819
Name:WOLFSON, JAKE NATHAN
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:NATHAN
Last Name:WOLFSON
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 1:14 MUD RD
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1410
Mailing Address - Country:US
Mailing Address - Phone:516-662-4063
Mailing Address - Fax:
Practice Address - Street 1:14 MUD RD
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1410
Practice Address - Country:US
Practice Address - Phone:516-662-4063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician