Healthcare Provider Details

I. General information

NPI: 1487216800
Provider Name (Legal Business Name): JESSICA HOPE ELLISON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LILIHA ST
HONOLULU HI
96817-1646
US

IV. Provider business mailing address

1177 QUEEN ST APT 2707
HONOLULU HI
96814-4146
US

V. Phone/Fax

Practice location:
  • Phone: 808-547-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number369
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: