Provider Demographics
NPI:1134211915
Name:WOOD, JAKE RICHARD (CP, FAAOP)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:RICHARD
Last Name:WOOD
Suffix:
Gender:M
Credentials:CP, FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ORTHOTICS AND PROSTHETICS ASSOCIATES, INC
Mailing Address - Street 2:10506 WEST BLUEMOUND ROAD
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-257-2727
Mailing Address - Fax:414-257-9898
Practice Address - Street 1:ORTHOTICS AND PROSTHETICS ASSOCIATES, INC
Practice Address - Street 2:10506 WEST BLUEMOUND ROAD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-257-2727
Practice Address - Fax:414-257-9898
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIC.P., 1307224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1242120001Medicare ID - Type UnspecifiedPROVIDER #
WI41785600Medicaid