Healthcare Provider Details

I. General information

NPI: 1134740301
Provider Name (Legal Business Name): JAKE STEPHEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 RICHMOND RD
STATEN ISLAND NY
10304-2322
US

IV. Provider business mailing address

1630 RICHMOND RD
STATEN ISLAND NY
10304-2322
US

V. Phone/Fax

Practice location:
  • Phone: 718-648-1234
  • Fax: 734-936-6585
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number335037
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number5101027830
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number335037
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: