Healthcare Provider Details

I. General information

NPI: 1740873496
Provider Name (Legal Business Name): MR. JACOB GIOVANNI HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2021
Last Update Date: 02/13/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9051 LAUREL CANYON BLVD SPC 50
SUN VALLEY CA
91352-1766
US

IV. Provider business mailing address

9051 LAUREL CANYON BLVD SPC 50
SUN VALLEY CA
91352-1766
US

V. Phone/Fax

Practice location:
  • Phone: 818-641-0438
  • Fax:
Mailing address:
  • Phone: 818-641-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number302550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: