Healthcare Provider Details

I. General information

NPI: 1205566593
Provider Name (Legal Business Name): JESSA EMMERICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 HOOHANA ST STE F
KAHULUI HI
96732-3527
US

IV. Provider business mailing address

28 MANO DR
KULA HI
96790-8526
US

V. Phone/Fax

Practice location:
  • Phone: 808-446-2032
  • Fax: 833-565-3144
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberT-000972530
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: