Provider Demographics
NPI:1710241138
Name:MONTANA, JESSICA A (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:MONTANA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 OLINDA RD
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-7360
Mailing Address - Country:US
Mailing Address - Phone:808-633-6123
Mailing Address - Fax:
Practice Address - Street 1:1170 MAKAWAO AVE STE 103
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9448
Practice Address - Country:US
Practice Address - Phone:808-633-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI981171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIACU-981OtherHAWAII STATE LICENSE