Provider Demographics
NPI:1427129196
Name:WASAN, JAMAL FULANI (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:FULANI
Last Name:WASAN
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 1:68-1774 LAIE ST
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-5125
Mailing Address - Country:US
Mailing Address - Phone:808-883-0922
Mailing Address - Fax:
Practice Address - Street 1:76-6225 KUAKINI HWY
Practice Address - Street 2:HILLSIDE PLAZA SUITE B105
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3211
Practice Address - Country:US
Practice Address - Phone:808-883-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC 9101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000596536OtherHMSA-QUEST