Healthcare Provider Details

I. General information

NPI: 1427129196
Provider Name (Legal Business Name): JAMAL FULANI WASAN PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76-6225 KUAKINI HWY HILLSIDE PLAZA SUITE B105
KAILUA KONA HI
96740-3211
US

IV. Provider business mailing address

68-1774 LAIE ST
WAIKOLOA HI
96738-5125
US

V. Phone/Fax

Practice location:
  • Phone: 808-883-0922
  • Fax:
Mailing address:
  • Phone: 808-883-0922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC 9
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: