Healthcare Provider Details

I. General information

NPI: 1770451668
Provider Name (Legal Business Name): JACOB YEAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 10/24/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 S HAMEL RD APT D
LOS ANGELES CA
90048-3800
US

IV. Provider business mailing address

317 S HAMEL RD APT D
LOS ANGELES CA
90048-3800
US

V. Phone/Fax

Practice location:
  • Phone: 503-269-7204
  • Fax:
Mailing address:
  • Phone: 503-269-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number100069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: