Provider Demographics
NPI:1912117953
Name:FRADENBURG, JAN
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:
Last Name:FRADENBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:FRADENBURG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MFT
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:HOLUALOA
Mailing Address - State:HI
Mailing Address - Zip Code:96725-0161
Mailing Address - Country:US
Mailing Address - Phone:808-345-2429
Mailing Address - Fax:808-325-1313
Practice Address - Street 1:74-5622 ALAPA ST
Practice Address - Street 2:SUITE 202
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3108
Practice Address - Country:US
Practice Address - Phone:808-345-2429
Practice Address - Fax:808-325-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT - 8106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist