Healthcare Provider Details

I. General information

NPI: 1396792966
Provider Name (Legal Business Name): MARIELIS JEPSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 S KIHEI RD SUITE 302 AZEKA MAKAI SHOPPING CENTER
KIHEI HI
96753-8240
US

IV. Provider business mailing address

PO BOX 724
KIHEI HI
96753-0724
US

V. Phone/Fax

Practice location:
  • Phone: 808-875-8737
  • Fax:
Mailing address:
  • Phone: 808-875-8737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number608
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: