# JACK F LAKE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1427069889
- **Gender:** Man
- **Credential:** PA-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | PA10001841 | WA | Yes |

## Other

- **Enumeration date:** 08/11/2006
- **Last updated:** 11/16/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0186925 | STATE L&I | WA |
| 05 | — | 8401788 | — | WA |
| 01 | — | 8940030 | STATE CRIME VICTIMS | WA |
| 01 | — | P00153517 | RAILROAD | WA |