Provider Demographics
NPI:1598329708
Name:LASTIMADO, JAELENE KANANI (RBT)
Entity Type:Individual
Prefix:
First Name:JAELENE
Middle Name:KANANI
Last Name:LASTIMADO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:JAELENE
Other - Middle Name:KANANI
Other - Last Name:LASTIMADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:16-566 KEAAU PAHOA RD STE 188
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8137
Mailing Address - Country:US
Mailing Address - Phone:808-333-8193
Mailing Address - Fax:
Practice Address - Street 1:17943 KUKUI CAMP RD
Practice Address - Street 2:
Practice Address - City:MT VIEW
Practice Address - State:HI
Practice Address - Zip Code:96771
Practice Address - Country:US
Practice Address - Phone:808-333-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-84668106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician