Provider Demographics
NPI:1982844304
Name:JACKSON FRIEDMAN D.O .PLLC
Entity Type:Organization
Organization Name:JACKSON FRIEDMAN D.O .PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:808-354-1698
Mailing Address - Street 1:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-0840
Mailing Address - Country:US
Mailing Address - Phone:808-354-1698
Mailing Address - Fax:
Practice Address - Street 1:100 KEOKEA PL
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-7450
Practice Address - Country:US
Practice Address - Phone:808-354-1698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1397204D00000X
NY237180204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002HJ1Medicare PIN
NY168878Medicare UPIN