Healthcare Provider Details

I. General information

NPI: 1285239889
Provider Name (Legal Business Name): JACOB JOHN ESLICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 ALA MOANA BLVD STE 1
HONOLULU HI
96814-4262
US

IV. Provider business mailing address

2417 NAAI ST
HONOLULU HI
96819-2836
US

V. Phone/Fax

Practice location:
  • Phone: 808-585-1424
  • Fax:
Mailing address:
  • Phone: 808-497-6366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-75087
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: