Provider Demographics
NPI:1093421257
Name:BRYAN FITZPATRICK, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BRYAN FITZPATRICK
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 1:438 KUAMOO ST APT 304
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-2053
Mailing Address - Country:US
Mailing Address - Phone:858-210-8121
Mailing Address - Fax:
Practice Address - Street 1:1330 ALA MOANA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4262
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician