Provider Demographics
NPI:1326911173
Name:HAILESELASSIE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HAILESELASSIE
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 1:1426 S KENMORE ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1968 S COAST HWY # 2862
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3681
Practice Address - Country:US
Practice Address - Phone:909-663-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician