Provider Demographics
NPI:1619786175
Name:WOLFBERG, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:WOLFBERG
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 1:1284 AUPAPAOHE ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4136
Mailing Address - Country:US
Mailing Address - Phone:267-664-7749
Mailing Address - Fax:
Practice Address - Street 1:1284 AUPAPAOHE ST
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4136
Practice Address - Country:US
Practice Address - Phone:267-664-7749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-15786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist