Provider Demographics
NPI:1699057380
Name:ROSE, JOLYN (LAC)
Entity type:Individual
Prefix:
First Name:JOLYN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-0441
Mailing Address - Country:US
Mailing Address - Phone:808-639-3070
Mailing Address - Fax:
Practice Address - Street 1:4-356 KUHIO HWY
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1413
Practice Address - Country:US
Practice Address - Phone:808-639-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI998171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist