Provider Demographics
NPI:1407985393
Name:HENNESS, JACOB JON (LMT MA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:JON
Last Name:HENNESS
Suffix:
Gender:M
Credentials:LMT MA
Other - Prefix:MR
Other - First Name:JACOB
Other - Middle Name:JON
Other - Last Name:HENNESS
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:LMT MA
Mailing Address - Street 1:5638 W GLENROSA
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031
Mailing Address - Country:US
Mailing Address - Phone:623-247-9621
Mailing Address - Fax:
Practice Address - Street 1:3543 N 7 ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014
Practice Address - Country:US
Practice Address - Phone:602-263-8484
Practice Address - Fax:602-263-3697
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT04134225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist