Provider Demographics
NPI:1992575922
Name:ZOSIMO, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:ZOSIMO
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 1:2 YARMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-2009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1217
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician