Provider Demographics
NPI:1972990984
Name:VISCO, JAKE FORREST (BA)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:FORREST
Last Name:VISCO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 VESPER LN
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-4394
Mailing Address - Country:US
Mailing Address - Phone:508-228-2689
Mailing Address - Fax:508-228-3613
Practice Address - Street 1:20 VESPER LN
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-4394
Practice Address - Country:US
Practice Address - Phone:508-228-2689
Practice Address - Fax:508-228-3613
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor