Healthcare Provider Details

I. General information

NPI: 1801511019
Provider Name (Legal Business Name): JACOB D RUSSELL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-1001 KAIMALIE ST # 106
EWA BEACH HI
96706-6247
US

IV. Provider business mailing address

91-1001 KAIMALIE ST # 106
EWA BEACH HI
96706-6247
US

V. Phone/Fax

Practice location:
  • Phone: 808-774-7817
  • Fax:
Mailing address:
  • Phone: 808-774-7817
  • Fax: 808-774-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1658
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: