Provider Demographics
NPI:1912223355
Name:HERNANDEZ, JACOB ANDREW (CAC II)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11750 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1107
Mailing Address - Country:US
Mailing Address - Phone:303-452-9133
Mailing Address - Fax:303-452-9133
Practice Address - Street 1:11750 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-1107
Practice Address - Country:US
Practice Address - Phone:303-452-9133
Practice Address - Fax:303-452-9133
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB 6822101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)