Provider Demographics
NPI:1851031850
Name:PEDERSEN-FUKUNAGA, JORDAN Y K (RN)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:Y K
Last Name:PEDERSEN-FUKUNAGA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:HI
Mailing Address - Zip Code:96785-0626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:944 W KAWAILANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3298
Practice Address - Country:US
Practice Address - Phone:808-959-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI92279163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse