Provider Demographics
NPI:1679355390
Name:JACK, DAVID M
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:JACK
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 1:1132 BISHOP ST UNIT 1121
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-6712
Mailing Address - Country:US
Mailing Address - Phone:505-577-1107
Mailing Address - Fax:
Practice Address - Street 1:203 KAPAA QUARRY PL
Practice Address - Street 2:5002
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-247-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician