Healthcare Provider Details

I. General information

NPI: 1336896729
Provider Name (Legal Business Name): JESSE OKUMURA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 PALEKAUA ST
HONOLULU HI
96816-4755
US

IV. Provider business mailing address

PO BOX 22005
HONOLULU HI
96823-2005
US

V. Phone/Fax

Practice location:
  • Phone: 808-780-0014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-115767
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: