Healthcare Provider Details

I. General information

NPI: 1790011682
Provider Name (Legal Business Name): JILL H VASCONCELLOS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-377 HUALALAI RD
KAILUA KONA HI
96740-9724
US

IV. Provider business mailing address

75-377 HUALALAI RD
KAILUA KONA HI
96740-9724
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-0774
  • Fax: 808-329-0776
Mailing address:
  • Phone: 808-329-0774
  • Fax: 808-329-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: