Provider Demographics
NPI:1770385379
Name:LIEBMAN, JACOB SAMUEL (LMT, RN)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SAMUEL
Last Name:LIEBMAN
Suffix:
Gender:
Credentials:LMT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-290 HANAPOULI CIR APT 6J
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3708
Mailing Address - Country:US
Mailing Address - Phone:503-314-9328
Mailing Address - Fax:
Practice Address - Street 1:2045 LAUWILIWILI ST
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-3900
Practice Address - Country:US
Practice Address - Phone:503-314-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-68669163WP0000X
HIMAT-15682225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Multi-Specialty