Healthcare Provider Details

I. General information

NPI: 1700218658
Provider Name (Legal Business Name): GINGER JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85-175 FARRINGTON HWY # 309
WAIANAE HI
96792-2154
US

IV. Provider business mailing address

85-175 FARRINGTON HWYB309
WAIANAE TX
96792
US

V. Phone/Fax

Practice location:
  • Phone: 808-548-9206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number13085
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: