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General NPI Number Information
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NPI Number | 1730508664
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Entity Type | Individual
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Provider Name | JAKE CAVENAUGH
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Gender | Male
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Dates
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Enumeration Date | 04/08/2014
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Last Update Date | 04/08/2014
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Provider Practice Location Address
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Address Line | 15 SALEM CHURCH RD
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City | TIFTON
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State | GA
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Zip | 31793-6754
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Country | US
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Telephone | 229-392-0558
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Fax |
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Provider Business Mailing Address
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Address Line | 15 SALEM CHURCH RD
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City | TIFTON
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State | GA
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Zip | 31793-6754
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Country | US
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Telephone | 229-392-0558
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number |
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License Number State |
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