Provider Demographics
NPI:1922880319
Name:FATURECHI, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FATURECHI
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 1:14500 ROSCOE BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4194
Mailing Address - Country:US
Mailing Address - Phone:310-849-8024
Mailing Address - Fax:
Practice Address - Street 1:14500 ROSCOE BLVD FL 4
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4194
Practice Address - Country:US
Practice Address - Phone:310-849-8024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor