Healthcare Provider Details

I. General information

NPI: 1043974819
Provider Name (Legal Business Name): JACOB KERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 UNIVERSITY AVE STE 115
LA MESA CA
91942-0523
US

IV. Provider business mailing address

4584 HARBINSON AVE
LA MESA CA
91942-8765
US

V. Phone/Fax

Practice location:
  • Phone: 858-256-6736
  • Fax:
Mailing address:
  • Phone: 951-526-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: