Provider Demographics
NPI:1982303855
Name:WATANABE, JORDYN
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:WATANABE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-216 HOONI PL
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-4871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98-1005 MOANALUA RD SPC 410
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4702
Practice Address - Country:US
Practice Address - Phone:808-488-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI5604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist