Provider Demographics
NPI:1063517324
Name:BRENNAN, JERRY M (PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 KAUMAKANI ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1827
Mailing Address - Country:US
Mailing Address - Phone:808-538-0343
Mailing Address - Fax:
Practice Address - Street 1:651 KAUMAKANI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-1827
Practice Address - Country:US
Practice Address - Phone:808-538-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-277103T00000X
HI532-92103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI067935000OtherMAGELLAN
HI99-0302920OtherTRI-CARE
HIPSY-277OtherKAISER
HI00013417OtherHMSA
HI99-0302920OtherCIGNA
HI01269301OtherALOHACARE
HI192826OtherSUMMERLIN
HI99-0302920OtherHAWAII LABORERS
HI0000013417OtherBLUE CROSS
HI99-0302920OtherHMA
HI01269301Medicaid
HIPSY-277OtherMASS MUTUAL
HI01269301Medicaid