Healthcare Provider Details

I. General information

NPI: 1578251567
Provider Name (Legal Business Name): NICHOLAS JAMES JAKUPCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

5244 SHADY DELL CIR
NOBLESVILLE IN
46062-9366
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5506
  • Fax:
Mailing address:
  • Phone: 317-590-2403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: