Provider Demographics
NPI:1679123327
Name:GAGNE, JAKE M (ATC)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:M
Last Name:GAGNE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WOOSTER PL
Mailing Address - Street 2:APT. A5
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-4006
Mailing Address - Country:US
Mailing Address - Phone:207-710-4231
Mailing Address - Fax:
Practice Address - Street 1:600 PARK ST
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4009
Practice Address - Country:US
Practice Address - Phone:785-628-4376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24014342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer