Provider Demographics
NPI:1780393975
Name:HAAG, JESSICA ANNLEILANI (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNLEILANI
Last Name:HAAG
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:PO BOX 2116
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-8116
Mailing Address - Country:US
Mailing Address - Phone:808-861-3902
Mailing Address - Fax:
Practice Address - Street 1:92-1288 KIKAHA ST APT 74
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-1564
Practice Address - Country:US
Practice Address - Phone:808-861-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-17310225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist