Healthcare Provider Details

I. General information

NPI: 1831983188
Provider Name (Legal Business Name): JACOB HANCOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CHARLESTON BLVD
LAS VEGAS NV
89104-1512
US

IV. Provider business mailing address

2560 BUSINESS PKWY STE A
MINDEN NV
89423-8961
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-6929
  • Fax: 702-463-6929
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: