Healthcare Provider Details

I. General information

NPI: 1801822093
Provider Name (Legal Business Name): SOPHIE JAKOVICH O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 WASHINGTON ST
WATERTOWN NY
13601-4034
US

IV. Provider business mailing address

522 WASHINGTON ST APT 202
WATERTOWN NY
13601-4053
US

V. Phone/Fax

Practice location:
  • Phone: 315-785-4088
  • Fax: 315-786-4847
Mailing address:
  • Phone: 315-767-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT 11501
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number009270-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: