Provider Demographics
NPI:1356515498
Name:JICHA, LISA KT (LCSW, CSAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KT
Last Name:JICHA
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 893542
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-0542
Mailing Address - Country:US
Mailing Address - Phone:808-783-7860
Mailing Address - Fax:
Practice Address - Street 1:100 KAHELU AVE STE 232
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-3962
Practice Address - Country:US
Practice Address - Phone:808-625-7448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2021-08-04
Deactivation Date:2011-01-18
Deactivation Code:
Reactivation Date:2017-08-24
Provider Licenses
StateLicense IDTaxonomies
HI32461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical