Provider Demographics
NPI:1477789014
Name:FORTUNE, JASON (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 S KIHEI RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8635
Mailing Address - Country:US
Mailing Address - Phone:808-879-0638
Mailing Address - Fax:808-879-0630
Practice Address - Street 1:2395 S. KIHEI RD.
Practice Address - Street 2:SUITE 201
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753
Practice Address - Country:US
Practice Address - Phone:808-879-0638
Practice Address - Fax:808-879-0630
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC1028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor