Provider Demographics
NPI:1245219849
Name:JACKSON, ROBERT E (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 701089
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96709-1089
Mailing Address - Country:US
Mailing Address - Phone:808-377-4300
Mailing Address - Fax:808-484-1129
Practice Address - Street 1:91-1010 SHANGRILA ST STE 105
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2176
Practice Address - Country:US
Practice Address - Phone:808-377-4300
Practice Address - Fax:808-484-1129
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-809103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist