Provider Demographics
NPI:1497385702
Name:JAKUBOWSKI, PETER EDWARD (LPN)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:EDWARD
Last Name:JAKUBOWSKI
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 STONE ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1933
Mailing Address - Country:US
Mailing Address - Phone:315-813-2760
Mailing Address - Fax:
Practice Address - Street 1:6054 CAVANAUGH RD
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13403-2411
Practice Address - Country:US
Practice Address - Phone:315-534-0730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29554301251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care