Provider Demographics
NPI:1598522369
Name:RICHARDSON, JILL MARIE (MASSAGE MAT 5245)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MASSAGE MAT 5245
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 KAHUNA RD # N
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-9027
Mailing Address - Country:US
Mailing Address - Phone:808-651-0717
Mailing Address - Fax:
Practice Address - Street 1:4569 KUKUI ST STE 201
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1775
Practice Address - Country:US
Practice Address - Phone:808-651-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI5245225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist