Provider Demographics
NPI:1013661826
Name:PROSCIA, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PROSCIA
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 1:26 STRAWBERRY HILL AVE APT 6C
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2615
Mailing Address - Country:US
Mailing Address - Phone:914-462-0868
Mailing Address - Fax:
Practice Address - Street 1:1011 HIGH RIDGE RD STE 300
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1610
Practice Address - Country:US
Practice Address - Phone:203-200-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1385103K00000X
CTBACB560988103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst