Provider Demographics
NPI:1811398357
Name:FREITAS, JILLIAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:FREITAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MAHALANI ST RM 21
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2521
Mailing Address - Country:US
Mailing Address - Phone:808-244-4647
Mailing Address - Fax:
Practice Address - Street 1:95 MAHALANI ST RM 21
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2521
Practice Address - Country:US
Practice Address - Phone:808-244-4647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673381Medicaid