Provider Demographics
NPI:1184184244
Name:HATTENBACH, JACOB DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:HATTENBACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 WILSHIRE BLVD # 144
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 OCEAN PARK BLVD # 1003
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2905
Practice Address - Country:US
Practice Address - Phone:323-709-3657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318847-A171100000X
MI5101027170208100000X
NY318847208100000X
CA20A226222081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No171100000XOther Service ProvidersAcupuncturist
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine