Provider Demographics
NPI:1740810704
Name:QUENGA, JEREMY JACOB I (RBT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JACOB
Last Name:QUENGA
Suffix:I
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1215 KANEANA ST # 13B
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91-1180 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707
Practice Address - Country:US
Practice Address - Phone:808-682-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBACB315759106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician