Provider Demographics
NPI:1588039648
Name:CUNNINGHAM, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15-2662 PAHOA VILLAGE RD # 306-105
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-7730
Mailing Address - Country:US
Mailing Address - Phone:510-695-4304
Mailing Address - Fax:
Practice Address - Street 1:1221 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4271
Practice Address - Country:US
Practice Address - Phone:808-607-0117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
HI677103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst