Healthcare Provider Details

I. General information

NPI: 1255147849
Provider Name (Legal Business Name): JAKE ROBERT HENIGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E SHAW AVE STE 149
FRESNO CA
93710-7903
US

IV. Provider business mailing address

8033 N GLENN AVE APT 105
FRESNO CA
93711-6804
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-9710
  • Fax: 559-554-9710
Mailing address:
  • Phone: 650-649-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1255147849
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: