Provider Demographics
NPI:1235360801
Name:MAIN, JODY ANN
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:ANN
Last Name:MAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JODY
Other - Middle Name:ANN
Other - Last Name:SCHMITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:91-1175 KUANOO ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4634
Mailing Address - Country:US
Mailing Address - Phone:808-220-1942
Mailing Address - Fax:
Practice Address - Street 1:91-2301 OLD FT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3602
Practice Address - Country:US
Practice Address - Phone:808-677-2525
Practice Address - Fax:808-677-2570
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI39439163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health