Provider Demographics
NPI:1427357581
Name:JACOB HANSON DC INC
Entity Type:Organization
Organization Name:JACOB HANSON DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-840-0056
Mailing Address - Street 1:1746 E SOUTH MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-8074
Mailing Address - Country:US
Mailing Address - Phone:701-306-3579
Mailing Address - Fax:602-840-4056
Practice Address - Street 1:2824 E INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6863
Practice Address - Country:US
Practice Address - Phone:602-840-0056
Practice Address - Fax:602-840-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7655261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122117Medicare PIN