Healthcare Provider Details

I. General information

NPI: 1114845633
Provider Name (Legal Business Name): JACOB FUENTES DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 THIRD ST
NEW CITY NY
10956-4929
US

IV. Provider business mailing address

29 THIRD ST
NEW CITY NY
10956-4929
US

V. Phone/Fax

Practice location:
  • Phone: 845-708-8885
  • Fax: 845-708-8884
Mailing address:
  • Phone: 845-708-8885
  • Fax: 845-708-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number014086
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: