Healthcare Provider Details

I. General information

NPI: 1760009062
Provider Name (Legal Business Name): JAKE HERNANDEZ PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N PARK AVE STE 201
WINTER PARK FL
32789-3268
US

IV. Provider business mailing address

442 5TH AVE
NEW YORK NY
10018-2794
US

V. Phone/Fax

Practice location:
  • Phone: 929-295-7822
  • Fax: 929-202-2629
Mailing address:
  • Phone: 929-295-7822
  • Fax: 929-202-2629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11014943
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403679
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number732427
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: