Provider Demographics
NPI:1396792966
Name:JEPSON, MARIELIS (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARIELIS
Middle Name:
Last Name:JEPSON
Suffix:
Gender:F
Credentials:PSYD
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 724
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-0724
Mailing Address - Country:US
Mailing Address - Phone:808-875-8737
Mailing Address - Fax:
Practice Address - Street 1:1280 S KIHEI RD
Practice Address - Street 2:SUITE 302 AZEKA MAKAI SHOPPING CENTER
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8240
Practice Address - Country:US
Practice Address - Phone:808-875-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539611Medicaid
HI539611Medicaid
HIH56824Medicare ID - Type Unspecified