Provider Demographics
NPI:1053092932
Name:CORTES, JAKE JOHN CARREON
Entity type:Individual
Prefix:
First Name:JAKE JOHN
Middle Name:CARREON
Last Name:CORTES
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 1:821 N EUTAW ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4648
Mailing Address - Country:US
Mailing Address - Phone:410-225-9185
Mailing Address - Fax:
Practice Address - Street 1:821 N EUTAW ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4648
Practice Address - Country:US
Practice Address - Phone:410-225-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP54186164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse