Provider Demographics
NPI:1124337803
Name:DRAKE, JON (AUD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OAKLAND HILLS LN
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6429
Mailing Address - Country:US
Mailing Address - Phone:830-385-2034
Mailing Address - Fax:
Practice Address - Street 1:7001 PROSPECT PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4311
Practice Address - Country:US
Practice Address - Phone:505-764-0036
Practice Address - Fax:505-764-0446
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80582237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid