Provider Demographics
NPI:1306406228
Name:WALLACE, AJA JEANETTE (LMHC)
Entity Type:Individual
Prefix:
First Name:AJA
Middle Name:JEANETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 MANANAI PL APT T
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-1872
Mailing Address - Country:US
Mailing Address - Phone:808-725-7519
Mailing Address - Fax:
Practice Address - Street 1:447 MANANAI PL APT T
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-1872
Practice Address - Country:US
Practice Address - Phone:808-725-7519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health