Basic Information
| Provider Information | |||||||||
| NPI: | 1508206772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 AIRPORT ROAD | ||||||||
| Address2: | |||||||||
| City: | KWETHLUK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077576627 | ||||||||
| FaxNumber: | 9077576626 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHIEF EDDIE HOFFMAN HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436300 | ||||||||
| FaxNumber: | 9075436366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.