Provider Demographics
NPI:1215624929
Name:RENO-MEDEIROS, JENNIFER BLYTHE (RBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BLYTHE
Last Name:RENO-MEDEIROS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 5063
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9504
Mailing Address - Country:US
Mailing Address - Phone:808-333-6443
Mailing Address - Fax:
Practice Address - Street 1:15-1560 29TH AVENUE
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-9674
Practice Address - Country:US
Practice Address - Phone:808-333-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-192529106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician