Provider Demographics
NPI:1780455725
Name:VELLALOS, JAYDE DK
Entity type:Individual
Prefix:
First Name:JAYDE
Middle Name:DK
Last Name:VELLALOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:15-2714 PAHOA VILLAGE RD STE H1-285
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-9715
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician