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General NPI Number Information
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NPI Number | 1952816977
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Entity Type | Individual
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Provider Name | JACQUELYN A WATERS MAT
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Gender | Female
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Dates
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Enumeration Date | 12/13/2017
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Last Update Date | 12/13/2017
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Provider Practice Location Address
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Address Line | 64-5117 WHITE RD
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City | KAMUELA
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State | HI
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Zip | 96743-8239
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Country | US
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Telephone | 808-344-0429
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Fax |
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Provider Business Mailing Address
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Address Line | 67-1272 KALEIOHU ST
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City | KAMUELA
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State | HI
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Zip | 96743-8396
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Country | US
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Telephone | 808-344-0429
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Fax | 808-769-4985
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MAT-2697
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License Number State | HI
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