Provider Demographics
NPI:1720223928
Name:DEEGAN, JACQUELINE NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:DEEGAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-1233 KAHUKAI ST
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-8214
Mailing Address - Country:US
Mailing Address - Phone:808-965-9603
Mailing Address - Fax:
Practice Address - Street 1:15-2891 PAHOA VILLAGE RD.
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-8214
Practice Address - Country:US
Practice Address - Phone:808-965-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 10071, MAE 2420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist