Basic Information
| Provider Information | |||||||||
| NPI: | 1750535324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURNE | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 542 4TH AVE | ||||||||
| Address2: | SUITE 234 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074564584 | ||||||||
| FaxNumber: | 9074565524 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 BARROW ST | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995013631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072583498 | ||||||||
| FaxNumber: | 9072790171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 11/10/2008 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | CM4106 | 05 | AK | MEDICAID |