Provider Demographics
NPI:1063522407
Name:JAKES, THERESA MICHELLE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MICHELLE
Last Name:JAKES
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-8921
Mailing Address - Country:US
Mailing Address - Phone:386-574-7392
Mailing Address - Fax:
Practice Address - Street 1:495 BIRCHWOOD LN
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-8921
Practice Address - Country:US
Practice Address - Phone:386-574-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 2740171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor