Provider Demographics
NPI:1417524984
Name:STOPP, JAKE ANDREW
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ANDREW
Last Name:STOPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4733
Mailing Address - Country:US
Mailing Address - Phone:918-457-8495
Mailing Address - Fax:
Practice Address - Street 1:513 TALLEY ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-6335
Practice Address - Country:US
Practice Address - Phone:918-457-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist