Provider Demographics
NPI:1245041128
Name:TAGALOG, JENISE STARR
Entity type:Individual
Prefix:
First Name:JENISE
Middle Name:STARR
Last Name:TAGALOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215A N KALAHEO AVE
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2317
Mailing Address - Country:US
Mailing Address - Phone:808-321-5335
Mailing Address - Fax:
Practice Address - Street 1:1001 KAMOKILA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2096
Practice Address - Country:US
Practice Address - Phone:808-591-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRBT-25-404140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician