Provider Demographics
NPI:1003679473
Name:HERNANDEZ, JACOB (LAC)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SHERMAN PL APT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-3735
Mailing Address - Country:US
Mailing Address - Phone:201-674-2876
Mailing Address - Fax:
Practice Address - Street 1:176 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1121
Practice Address - Country:US
Practice Address - Phone:201-795-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00484200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist