Provider Demographics
NPI:1972287795
Name:ROWLAND, JACOB KENNETH
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:KENNETH
Last Name:ROWLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6818
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD STE 505
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6818
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-TRYGDU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker