Provider Demographics
NPI:1275317133
Name:TYRELL, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TYRELL
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 1:3844 HELVETIA DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5016
Mailing Address - Country:US
Mailing Address - Phone:860-367-3763
Mailing Address - Fax:907-331-0463
Practice Address - Street 1:5731 RADCLIFF DR # 1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3019
Practice Address - Country:US
Practice Address - Phone:907-339-4859
Practice Address - Fax:907-331-0463
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101559320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities