Provider Demographics
NPI:1144349259
Name:DAKE, JEANNIE GLORIA
Entity type:Individual
Prefix:MS
First Name:JEANNIE
Middle Name:GLORIA
Last Name:DAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 STROBACH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4243
Mailing Address - Country:US
Mailing Address - Phone:573-364-4667
Mailing Address - Fax:
Practice Address - Street 1:1101 STROBACH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4243
Practice Address - Country:US
Practice Address - Phone:573-364-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities