Provider Demographics
NPI:1073657128
Name:TAKAHASHI, JENNIFER MALIA (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MALIA
Last Name:TAKAHASHI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-4110
Mailing Address - Country:US
Mailing Address - Phone:808-737-1078
Mailing Address - Fax:
Practice Address - Street 1:1215 CENTER ST
Practice Address - Street 2:SUITE 203
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3209
Practice Address - Country:US
Practice Address - Phone:808-271-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000236216OtherHMSA-QUEST
HI500258Medicaid
HI23621-6OtherHMSA