Healthcare Provider Details

I. General information

NPI: 1386436087
Provider Name (Legal Business Name): JACKIE LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KAHELU AVE STE 226
MILILANI HI
96789-3962
US

IV. Provider business mailing address

100 KAHELU AVE STE 226
MILILANI HI
96789-3962
US

V. Phone/Fax

Practice location:
  • Phone: 808-621-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD-1518
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: