Provider Demographics
NPI:1932310265
Name:YATES, JAELENE L C K (MD, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAELENE
Middle Name:L C K
Last Name:YATES
Suffix:
Gender:F
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3288 MOANALUA RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1469
Mailing Address - Country:US
Mailing Address - Phone:808-432-0000
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:808-432-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14135207R00000X
HIMD-14135208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000279844OtherHMSA BILLING NUMBER
HI624818-01Medicaid
HI624818-01Medicaid