Provider Demographics
NPI:1003631391
Name:RALPH, JERRELL
Entity type:Individual
Prefix:
First Name:JERRELL
Middle Name:
Last Name:RALPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 HIKINA CT UNIT 102
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-5480
Mailing Address - Country:US
Mailing Address - Phone:757-297-0083
Mailing Address - Fax:
Practice Address - Street 1:91-1841 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1909
Practice Address - Country:US
Practice Address - Phone:808-681-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician