Basic Information
| Provider Information | |||||||||
| NPI: | 1093853624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DELDEN | ||||||||
| FirstName: | JACO | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1944A 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968162910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083818947 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 932 WARD AVE | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968142131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083818947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2007 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-1582 | HI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | A20852-8 | 01 | HI | HMSA | OTHER |