Provider Demographics
NPI:1164026712
Name:LOCKULU, JEAN PAULIN ENGBANDA
Entity Type:Individual
Prefix:MR
First Name:JEAN PAULIN
Middle Name:ENGBANDA
Last Name:LOCKULU
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 1:3211 PROVIDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-885-2280
Mailing Address - Fax:907-885-6613
Practice Address - Street 1:3211 PROVIDENCE DRIVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-885-2280
Practice Address - Fax:907-885-6613
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1584706Medicaid
AK1021118Medicaid