Provider Demographics
NPI:1205478625
Name:RIESSLAND, JASON LEE (LPN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:RIESSLAND
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:LEE
Other - Last Name:RIESSLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:475 KINOOLE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2900
Mailing Address - Country:US
Mailing Address - Phone:808-854-4275
Mailing Address - Fax:
Practice Address - Street 1:94-450 MOKUOLA STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797
Practice Address - Country:US
Practice Address - Phone:808-854-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILPN-18625164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse