Provider Demographics
NPI:1467868968
Name:LIS, JENNIFER A (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 SEASIDE AVE APT 704
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-2611
Mailing Address - Country:US
Mailing Address - Phone:609-468-2725
Mailing Address - Fax:
Practice Address - Street 1:1350 S KING ST STE 307
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2008
Practice Address - Country:US
Practice Address - Phone:609-468-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-4508225100000X
MD25060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD611406429OtherGROUP TIN