Provider Demographics
NPI:1932979929
Name:AGUAYO, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:AGUAYO
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 1:4521 TEMESCAL CANYON RD APT 202
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-4653
Mailing Address - Country:US
Mailing Address - Phone:951-514-9238
Mailing Address - Fax:
Practice Address - Street 1:1801 3RD ST
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2672
Practice Address - Country:US
Practice Address - Phone:951-777-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant