Provider Demographics
NPI:1205491297
Name:EUSTAQUIO, JACOB NICHOLAS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:NICHOLAS
Last Name:EUSTAQUIO
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 1:604 ULUMALU ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4325
Mailing Address - Country:US
Mailing Address - Phone:808-542-7235
Mailing Address - Fax:
Practice Address - Street 1:770 KAPIOLANI BLVD STE 104
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-5254
Practice Address - Country:US
Practice Address - Phone:808-596-9446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist