Provider Demographics
NPI:1336586106
Name:REISER, JACQUELYN VICTORIA VAUGHAN (DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:VICTORIA VAUGHAN
Last Name:REISER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68-024 APUHIHI ST APT 302W
Mailing Address - Street 2:
Mailing Address - City:WAIALUA
Mailing Address - State:HI
Mailing Address - Zip Code:96791-9423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66-590 KAMEHAMEHA HWY STE 2F
Practice Address - Street 2:
Practice Address - City:HALEIWA
Practice Address - State:HI
Practice Address - Zip Code:96712-1484
Practice Address - Country:US
Practice Address - Phone:808-260-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207975225100000X
HI37972251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist