Basic Information
| Provider Information | |||||||||
| NPI: | 1801822093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAKOVICH | ||||||||
| FirstName: | SOPHIE | ||||||||
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| Credential: | O.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 522 WASHINGTON ST | ||||||||
| Address2: | APT 202 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157678584 | ||||||||
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| Practice Location | |||||||||
| Address1: | 830 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157854088 | ||||||||
| FaxNumber: | 3157864847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OT 11501 | FL | N | Other Service Providers | Specialist | 225XP0200X | 009270-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Z088D | 01 | FL | BCBS | OTHER | 890272100 | 05 | FL | MEDICAID | OT 11501 | 01 | FL | OCCUPATIONAL THERAPY | OTHER |