Healthcare Provider Details

I. General information

NPI: 1982844304
Provider Name (Legal Business Name): JACKSON FRIEDMAN D.O .PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KEOKEA PL
KULA HI
96790-7450
US

IV. Provider business mailing address

PO BOX 840
KULA HI
96790-0840
US

V. Phone/Fax

Practice location:
  • Phone: 808-354-1698
  • Fax:
Mailing address:
  • Phone: 808-354-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number237180
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1397
License Number StateHI

VIII. Authorized Official

Name: JACKSON FRIEDMAN
Title or Position: PHYSICIAN
Credential: DO
Phone: 808-354-1698