NPIMap

Organization Active NPI

Crossroads Behavioral Health, Inc.

  • Clinical Psychologist
  • Kapolei, HI
National Provider Identifier
1013414770
Registry record updated Mar 13, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PSY809 Issued in HI
Legal business name
CROSSROADS BEHAVIORAL HEALTH, INC.
Practice address
91-1010 Shangrila St Ste 105
Kapolei, HI 96707-2176
Phone
(808) 377-4300
NPI assigned
Apr 10, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert E Jackson, PHDNPI 1245219849
Title
President
Phone
(808) 294-3493

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X PSY809 HI Primary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Child & Adolescent Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0804X

Addresses

Primary practice location

91-1010 Shangrila St Ste 105
Kapolei, HI 96707-2176

Mailing address

PO Box 701089
Kapolei, HI 96709-1089
Phone (808) 294-3493

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in HI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190712000402 HI Part B Supplier - Clinic/Group Practice 5092040048 Receives reassigned benefits from 3 practitioners
Practice locations: Kapolei, HI

National Provider Directory

National Provider Directory

Locations

91-1010 Shangrila St
Ste 105
Kapolei, HI 96707
Phone (808) 377-4300

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1523318400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1552435200000",
    "number": "1013414770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 701089",
            "city": "KAPOLEI",
            "state": "HI",
            "postal_code": "967091089",
            "telephone_number": "808-294-3493"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "91-1010 SHANGRILA ST STE 105",
            "city": "KAPOLEI",
            "state": "HI",
            "postal_code": "967072176",
            "telephone_number": "808-377-4300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROSSROADS BEHAVIORAL HEALTH, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-04-10",
        "last_updated": "2019-03-13",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "808-294-3493",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "HI",
            "license": "PSY809",
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kapolei, HI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.