Provider Demographics
NPI:1740873496
Name:HERNANDEZ, JACOB GIOVANNI
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:GIOVANNI
Last Name:HERNANDEZ
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 1:9051 LAUREL CANYON BLVD SPC 50
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-1766
Mailing Address - Country:US
Mailing Address - Phone:818-641-0438
Mailing Address - Fax:
Practice Address - Street 1:9051 LAUREL CANYON BLVD SPC 50
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-1766
Practice Address - Country:US
Practice Address - Phone:818-641-0438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3025502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer