Provider Demographics
NPI:1427779057
Name:HERNANDEZ, JACOB MANUEL (LPN)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MANUEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 2ND AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6242
Mailing Address - Country:US
Mailing Address - Phone:208-732-0959
Mailing Address - Fax:
Practice Address - Street 1:260 2ND AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6242
Practice Address - Country:US
Practice Address - Phone:208-732-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46268164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse