Provider Demographics
NPI:1003291972
Name:JOE, JACLYN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:JOE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16-566 KEAAU PAHOA RD STE 188-671
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8137
Mailing Address - Country:US
Mailing Address - Phone:714-213-2061
Mailing Address - Fax:
Practice Address - Street 1:15-1783 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749
Practice Address - Country:US
Practice Address - Phone:714-213-2061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-15-18756103K00000X
HI66103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst