Basic Information
| Provider Information | |||||||||
| NPI: | 1932335114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MYERS | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | IDMT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 673 MDG | ||||||||
| Address2: | 5955 ZEAMER AVENUE | ||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075805858 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5955 ZEAMER AVE | ||||||||
| Address2: | 3RD AMDS/ FLIGHT MEDICINE | ||||||||
| City: | ELMENDORF AFB | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995063702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075512025 | ||||||||
| FaxNumber: | 9075514001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1003X | N | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians | 1041C0700X | 124703 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.