Basic Information
| Provider Information | |||||||||
| NPI: | 1811074024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKUMOTO | ||||||||
| FirstName: | JENELYN | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERALTA | ||||||||
| OtherFirstName: | JENELYN | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 KAMOKILA BLVD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | KAPOLEI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967072014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086749595 | ||||||||
| FaxNumber: | 8086749696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 KAMOKILA BLVD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | KAPOLEI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967072014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086749595 | ||||||||
| FaxNumber: | 8086749696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2486 | HI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 56497301 | 05 | HI | MEDICAID | 0000251876 | 01 | HI | HMSA | OTHER |