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General NPI Number Information
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NPI Number | 1134740301
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Entity Type | Individual
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Provider Name | JAKE STEPHEN DO
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Gender | Male
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Dates
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Enumeration Date | 04/29/2020
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Last Update Date | 08/29/2025
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Provider Practice Location Address
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Address Line | 1630 RICHMOND RD
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City | STATEN ISLAND
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State | NY
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Zip | 10304-2322
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Country | US
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Telephone | 718-648-1234
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Fax | 734-936-6585
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Provider Business Mailing Address
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Address Line | 1630 RICHMOND RD
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City | STATEN ISLAND
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State | NY
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Zip | 10304-2322
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Country | US
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Telephone |
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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 | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 335037
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 5101027830
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 335037
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License Number State | NY
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