Healthcare Provider Details

I. General information

NPI: 1841994381
Provider Name (Legal Business Name): AMY JACKSON JACKSON REGISTERED BT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/31/2024
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 ALA MAKANI ST STE 200
KAHULUI HI
96732-3571
US

IV. Provider business mailing address

427 ALA MAKANI ST STE 200
KAHULUI HI
96732-3571
US

V. Phone/Fax

Practice location:
  • Phone: 808-204-2893
  • Fax:
Mailing address:
  • Phone: 808-204-2893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-253160
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT23-253160
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: