Provider Demographics
NPI:1114698818
Name:JACKSON, JAYLY JERMAYNE
Entity Type:Individual
Prefix:
First Name:JAYLY
Middle Name:JERMAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 UNIVERSITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4658
Mailing Address - Country:US
Mailing Address - Phone:907-729-2492
Mailing Address - Fax:907-729-3950
Practice Address - Street 1:3801 UNIVERSITY LAKE DR STE 205
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4658
Practice Address - Country:US
Practice Address - Phone:907-729-2492
Practice Address - Fax:907-729-3950
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health