Provider Demographics
NPI:1053027854
Name:BALLARD, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BALLARD
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 1:1290 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-6601
Mailing Address - Country:US
Mailing Address - Phone:760-709-0812
Mailing Address - Fax:
Practice Address - Street 1:1290 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-6601
Practice Address - Country:US
Practice Address - Phone:760-709-0812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator