Provider Demographics
NPI:1992319396
Name:JAKOWENKO, CARL EDWARD (PTA)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:EDWARD
Last Name:JAKOWENKO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 GORHAM RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9640
Mailing Address - Country:US
Mailing Address - Phone:207-839-2373
Mailing Address - Fax:
Practice Address - Street 1:378 GORHAM RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9640
Practice Address - Country:US
Practice Address - Phone:207-839-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant