Provider Demographics
NPI:1215569264
Name:TICKETT, CRYSTAL BESSIE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:BESSIE
Last Name:TICKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:907-442-7612
Mailing Address - Fax:907-437-2139
Practice Address - Street 1:80 BACK STREET
Practice Address - Street 2:
Practice Address - City:SHUNGNAK
Practice Address - State:AK
Practice Address - Zip Code:99778
Practice Address - Country:US
Practice Address - Phone:907-437-2138
Practice Address - Fax:907-437-2139
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health