Provider Demographics
NPI:1871087551
Name:SIMON, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:SIMON
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 1:22 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03290-5402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BERRY RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:NH
Practice Address - Zip Code:03290-5402
Practice Address - Country:US
Practice Address - Phone:617-990-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MA32532255A2300X
MA25194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer