Provider Demographics
NPI:1487488425
Name:BRUMBLAY, JACKSON KONANE (MA, LMT,)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:KONANE
Last Name:BRUMBLAY
Suffix:
Gender:M
Credentials:MA, LMT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NAKEKE PL
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-2749
Mailing Address - Country:US
Mailing Address - Phone:808-286-3891
Mailing Address - Fax:
Practice Address - Street 1:105 NAKEKE PL
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-2749
Practice Address - Country:US
Practice Address - Phone:808-286-3891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-16900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist