Provider Demographics
NPI:1104297084
Name:JENSON, NANI LEHUA O NALANI
Entity type:Individual
Prefix:
First Name:NANI
Middle Name:LEHUA O NALANI
Last Name:JENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ALTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92179-0001
Mailing Address - Country:US
Mailing Address - Phone:619-661-6500
Mailing Address - Fax:
Practice Address - Street 1:42-470 KALANIANAOLE HWY
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-266-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32428103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA370808447Medicaid