Provider Demographics
NPI:1346741287
Name:HULTBERG DYE, JENNIFER K (MED LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:HULTBERG DYE
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:DYE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED LPC
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-1559
Mailing Address - Country:US
Mailing Address - Phone:907-235-2970
Mailing Address - Fax:
Practice Address - Street 1:1044 E END RD STE C
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7205
Practice Address - Country:US
Practice Address - Phone:907-235-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK128345101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health