Provider Demographics
NPI:1356004378
Name:HIENEMAN, JACOB DOUGLAS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DOUGLAS
Last Name:HIENEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 TECH BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7863
Mailing Address - Country:US
Mailing Address - Phone:318-438-6796
Mailing Address - Fax:
Practice Address - Street 1:1202 TECH BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7863
Practice Address - Country:US
Practice Address - Phone:318-438-6796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician