Provider Demographics
NPI:1841824521
Name:DAVIS, JAKE COBURN (CPO, MSPO)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:COBURN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CPO, MSPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N MAIN ST STE 691
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1895
Mailing Address - Country:US
Mailing Address - Phone:801-820-0087
Mailing Address - Fax:801-820-2852
Practice Address - Street 1:635 N MAIN ST STE 691
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1895
Practice Address - Country:US
Practice Address - Phone:801-820-0087
Practice Address - Fax:801-820-2852
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO005925222Z00000X
CPO04745224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist