Provider Demographics
NPI:1356219273
Name:WILBOURN, JIMMIE
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
Last Name:WILBOURN
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 1:1001 QUEEN ST APT 4003
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-5242
Mailing Address - Country:US
Mailing Address - Phone:903-274-6794
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4920
Practice Address - Country:US
Practice Address - Phone:903-274-6794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist