Provider Demographics
NPI:1871259366
Name:WISDOM, JASON DONALD (MA, MED, LMFT, BCBA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DONALD
Last Name:WISDOM
Suffix:
Gender:M
Credentials:MA, MED, LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-501 KOAUKA LOOP APT A305
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5827
Mailing Address - Country:US
Mailing Address - Phone:360-470-2183
Mailing Address - Fax:
Practice Address - Street 1:98-501 KOAUKA LOOP APT 305
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4560
Practice Address - Country:US
Practice Address - Phone:360-470-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-805106H00000X
HIBA-610103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI003128Medicaid