Basic Information
| Provider Information | |||||||||
| NPI: | 1477951192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCURLOCK | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | OMENITSCH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OMENITSCH | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2949 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996692949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406743191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 230 E MARYDALE AVE | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072623119 | ||||||||
| FaxNumber: | 9072629290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 18453 | MD | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 147557 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.