Provider Demographics
NPI:1841594942
Name:JACOB, BENEDICT JOVELLANO
Entity Type:Individual
Prefix:MR
First Name:BENEDICT
Middle Name:JOVELLANO
Last Name:JACOB
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 1:1 HOOPER BLVD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1050
Mailing Address - Country:US
Mailing Address - Phone:619-628-8447
Mailing Address - Fax:
Practice Address - Street 1:1 HOOPER BLVD
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1050
Practice Address - Country:US
Practice Address - Phone:619-628-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman