Provider Demographics
NPI:1366819930
Name:TYLER, JENNIFER (MS, CDC-1, ICCTP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TYLER
Suffix:
Gender:F
Credentials:MS, CDC-1, ICCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 LAWTON DR # A
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-8913
Mailing Address - Country:US
Mailing Address - Phone:907-283-9947
Mailing Address - Fax:907-283-9949
Practice Address - Street 1:10735 KENAI SPUR HWY # 2B
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7859
Practice Address - Country:US
Practice Address - Phone:907-283-9947
Practice Address - Fax:907-283-9949
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-30
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1025263101YM0800X
AK1023805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1025263OtherSTATE OF AK
AK1023805OtherSTATE OF AK