Provider Demographics
NPI:1326852062
Name:KOPITZKE, JAKE (SSP)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:KOPITZKE
Suffix:
Gender:M
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1386 SUTTON BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-8306
Mailing Address - Country:US
Mailing Address - Phone:828-719-7667
Mailing Address - Fax:
Practice Address - Street 1:516 176TH ST E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8335
Practice Address - Country:US
Practice Address - Phone:253-800-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA551908G103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool