Basic Information
| Provider Information | |||||||||
| NPI: | 1396964870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANCHORAGE COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 FOLKER ST | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
| FaxNumber: | 9075632045 | ||||||||
| Practice Location | |||||||||
| Address1: | 4020 FOLKER ST | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
| FaxNumber: | 9075632045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9072615310 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MED., MAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | HC2394 | 05 | AK | MEDICAID |