Healthcare Provider Details

I. General information

NPI: 1104208271
Provider Name (Legal Business Name): MARY JILL ACKERMAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 WAIALAE AVE SUITE 305
HONOLULU HI
96816-3257
US

IV. Provider business mailing address

5101 PALAOLE PL
HONOLULU HI
96821-1530
US

V. Phone/Fax

Practice location:
  • Phone: 808-942-1144
  • Fax: 808-942-1142
Mailing address:
  • Phone: 808-377-1903
  • Fax: 808-377-1903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberLAC1
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: