Healthcare Provider Details

I. General information

NPI: 1093469553
Provider Name (Legal Business Name): JENNY EBESUTANI PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WARD AVE STE 665
HONOLULU HI
96814-1619
US

IV. Provider business mailing address

PO BOX 235665
HONOLULU HI
96823-3511
US

V. Phone/Fax

Practice location:
  • Phone: 808-304-1565
  • Fax:
Mailing address:
  • Phone: 808-304-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNY EBESUTANI
Title or Position: PSYCHOLOGIST, OWNER
Credential: PSYD
Phone: 808-304-1565