Healthcare Provider Details

I. General information

NPI: 1134186257
Provider Name (Legal Business Name): JERALD FRANK OGRISSEG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/26/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TAMC 1 JARRETT WHITE ROAD
HONOLULU HI
96859
US

IV. Provider business mailing address

TAMC 1 JARRETT WHITE ROAD
HONOLULU HI
96859
US

V. Phone/Fax

Practice location:
  • Phone: 509-368-7170
  • Fax:
Mailing address:
  • Phone: 509-368-7170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1072
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: