Provider Demographics
NPI:1386188720
Name:JESELNIK, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JESELNIK
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 1:1233 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4211
Mailing Address - Country:US
Mailing Address - Phone:907-317-1093
Mailing Address - Fax:
Practice Address - Street 1:1233 5TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4211
Practice Address - Country:US
Practice Address - Phone:907-317-1093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-04
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101139376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator