Provider Demographics
NPI:1578075271
Name:DILLON, JACQUELYN (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DILLON
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:PO BOX 880066
Mailing Address - Street 2:
Mailing Address - City:PUKALANI
Mailing Address - State:HI
Mailing Address - Zip Code:96788-0066
Mailing Address - Country:US
Mailing Address - Phone:808-281-5708
Mailing Address - Fax:
Practice Address - Street 1:2045 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1648
Practice Address - Country:US
Practice Address - Phone:808-242-8844
Practice Address - Fax:808-244-7414
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI7902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist