Provider Demographics
NPI:1932813060
Name:MARTIN, JONATHAN BRYON
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRYON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-1209 HAUONE ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-1543
Mailing Address - Country:US
Mailing Address - Phone:808-462-8528
Mailing Address - Fax:
Practice Address - Street 1:95-1091 AINAMAKUA DR
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-4252
Practice Address - Country:US
Practice Address - Phone:808-204-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-808261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)