Provider Demographics
NPI:1588015374
Name:ISHIDA, JIRO JERRY (PTA)
Entity Type:Individual
Prefix:MR
First Name:JIRO
Middle Name:JERRY
Last Name:ISHIDA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6129 SUMMER ST APT C
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-2361
Mailing Address - Country:US
Mailing Address - Phone:941-685-7806
Mailing Address - Fax:
Practice Address - Street 1:2230 LILIHA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1646
Practice Address - Country:US
Practice Address - Phone:808-547-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI249225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant