Provider Demographics
NPI:1801314646
Name:CISNEROS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CISNEROS
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:818-241-6823
Practice Address - Street 1:221 N KANSAS ST STE 700
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79901-1443
Practice Address - Country:US
Practice Address - Phone:915-242-2100
Practice Address - Fax:818-241-6823
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician