Provider Demographics
NPI:1336295286
Name:JACKSON, BRENDA A L (CNM)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:A L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:A
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45-602 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-2017
Mailing Address - Country:US
Mailing Address - Phone:808-432-3800
Mailing Address - Fax:
Practice Address - Street 1:45-602 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-2017
Practice Address - Country:US
Practice Address - Phone:808-432-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-89363L00000X, 363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54134302Medicaid
HI00A0229342OtherHMSA BILLING NUMBER
HI61565108Medicaid
HIQ17035Medicare UPIN
HI61565108Medicaid