Provider Demographics
NPI:1932646957
Name:BRADER, JESSIE (LAC LMT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:BRADER
Suffix:
Gender:F
Credentials:LAC LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77-6425 KUAKINI HWY # 9
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3213
Mailing Address - Country:US
Mailing Address - Phone:808-895-2900
Mailing Address - Fax:
Practice Address - Street 1:76-829 HUALALAI RD
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-9779
Practice Address - Country:US
Practice Address - Phone:808-895-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-28
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist