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General NPI Number Information
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NPI Number | 1033699541
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Entity Type | Individual
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Provider Name | JAKE FELLOW DPT
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Gender | Male
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Dates
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Enumeration Date | 08/15/2018
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Last Update Date | 08/15/2018
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Provider Practice Location Address
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Address Line | 11848 BERNARDO PLAZA CT STE 100
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City | SAN DIEGO
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State | CA
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Zip | 92128-2417
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Country | US
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Telephone | 858-217-2496
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Fax |
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Provider Business Mailing Address
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Address Line | 16631 ORCHARD BEND RD
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City | POWAY
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State | CA
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Zip | 92064-1713
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Country | US
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Telephone | 909-260-7739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | PT295188
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT295188
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License Number State | CA
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