Provider Demographics
NPI:1508554486
Name:LIGHTY, JENNIFER (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:LIGHTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73-1056 AHIKAWA ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-9408
Mailing Address - Country:US
Mailing Address - Phone:401-374-5060
Mailing Address - Fax:
Practice Address - Street 1:73-5563 OLOWALU ST # B200
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-5608
Practice Address - Country:US
Practice Address - Phone:401-374-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist