Provider Demographics
NPI:1346768876
Name:JELLUM, LEDA (DPT)
Entity Type:Individual
Prefix:
First Name:LEDA
Middle Name:
Last Name:JELLUM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MOKUAHI ST
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8963
Mailing Address - Country:US
Mailing Address - Phone:808-398-2552
Mailing Address - Fax:
Practice Address - Street 1:75 MAUI LANI ELUA PARKWAY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-243-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist