Provider Demographics
NPI:1447744719
Name:BLEECKER, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:BLEECKER
Suffix:
Gender:F
Credentials:
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 2073
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-2073
Mailing Address - Country:US
Mailing Address - Phone:808-854-5343
Mailing Address - Fax:
Practice Address - Street 1:1221 KILAUEA AVE STE 60
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4264
Practice Address - Country:US
Practice Address - Phone:808-969-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBA-504103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst