Provider Demographics
NPI:1841718962
Name:REDICK, JASON BUMANGLAG (LMFT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BUMANGLAG
Last Name:REDICK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 PIIKOI ST, SUITE 203
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814
Mailing Address - Country:US
Mailing Address - Phone:808-589-1829
Mailing Address - Fax:808-589-2610
Practice Address - Street 1:91-2128 OLD FT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1911
Practice Address - Country:US
Practice Address - Phone:808-589-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-815-0106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0002276625Medicaid