Provider Demographics
NPI:1003203092
Name:JOHNSON, JACKI (CHA)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SCHOOL BLVD
Mailing Address - Street 2:
Mailing Address - City:STEBBINS
Mailing Address - State:AK
Mailing Address - Zip Code:99671
Mailing Address - Country:US
Mailing Address - Phone:907-934-3311
Mailing Address - Fax:907-934-3312
Practice Address - Street 1:189 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:UNALAKLEET
Practice Address - State:AK
Practice Address - Zip Code:99684
Practice Address - Country:US
Practice Address - Phone:907-624-3535
Practice Address - Fax:907-624-3692
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-IIOtherCHA