Provider Demographics
NPI:1194168575
Name:JACOB, ANDREW H (LMT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:H
Last Name:JACOB
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 DATE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-4054
Mailing Address - Country:US
Mailing Address - Phone:808-349-3141
Mailing Address - Fax:
Practice Address - Street 1:2440 KUHIO AVE STE OS1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-3347
Practice Address - Country:US
Practice Address - Phone:808-349-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11932225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI11932OtherSTATE LICENSE NUMBER