Provider Demographics
NPI:1295444214
Name:FERNANDEZ, JACEY KEIANA
Entity type:Individual
Prefix:MISS
First Name:JACEY
Middle Name:KEIANA
Last Name:FERNANDEZ
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 1:502 KEAWE ST APT 616
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-3165
Mailing Address - Country:US
Mailing Address - Phone:209-894-5474
Mailing Address - Fax:
Practice Address - Street 1:564 SOUTH ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-5013
Practice Address - Country:US
Practice Address - Phone:808-591-1173
Practice Address - Fax:808-591-1174
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-22-240744106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician