=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992319396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL EDWARD JAKOWENKO PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 378 GORHAM RD
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-9640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-839-2373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 378 GORHAM RD
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-9640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-839-2373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PA4170
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------