Provider Demographics
NPI:1710347034
Name:DERRICKSON, JODA P (PHD, RD, ACSM EP-C)
Entity Type:Individual
Prefix:DR
First Name:JODA
Middle Name:P
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:PHD, RD, ACSM EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 KAWAILOA RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3145
Mailing Address - Country:US
Mailing Address - Phone:808-220-4165
Mailing Address - Fax:
Practice Address - Street 1:580 KAWAILOA RD
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3145
Practice Address - Country:US
Practice Address - Phone:808-220-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic