Provider Demographics
NPI:1558927160
Name:PUCCI, JAKE DONALD
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:DONALD
Last Name:PUCCI
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 1:121 COURT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5608
Mailing Address - Country:US
Mailing Address - Phone:718-858-7036
Mailing Address - Fax:
Practice Address - Street 1:121 COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5608
Practice Address - Country:US
Practice Address - Phone:718-858-7036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist