Provider Demographics
NPI:1376791707
Name:PENINSULA NEUROLOGY LLC
Entity Type:Organization
Organization Name:PENINSULA NEUROLOGY LLC
Other - Org Name:ALYESKA NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:907-262-7700
Mailing Address - Street 1:206 W ROCKWELL AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7411
Mailing Address - Country:US
Mailing Address - Phone:907-262-7700
Mailing Address - Fax:907-262-0809
Practice Address - Street 1:206 W ROCKWELL AVE
Practice Address - Street 2:STE 100
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7411
Practice Address - Country:US
Practice Address - Phone:907-262-7700
Practice Address - Fax:907-262-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK47952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0369Medicaid
133269Medicare UPIN