Provider Demographics
NPI:1750854816
Name:COHEN, JACOB SURYA (LAC, MTOM)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SURYA
Last Name:COHEN
Suffix:
Gender:M
Credentials:LAC, MTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6158 PACKARD ST.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035
Mailing Address - Country:US
Mailing Address - Phone:310-663-9916
Mailing Address - Fax:
Practice Address - Street 1:6404 WILSHIRE BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:323-852-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18370171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist