Provider Demographics
NPI:1942013925
Name:LIM, JAKE ERN (FNP-BC)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ERN
Last Name:LIM
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-1423
Mailing Address - Country:US
Mailing Address - Phone:617-816-9982
Mailing Address - Fax:
Practice Address - Street 1:260 E 188TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5302
Practice Address - Country:US
Practice Address - Phone:718-220-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2372624363L00000X
NY356332363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner