Provider Demographics
NPI:1386850469
Name:IRVINE, JODI ANN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:IRVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6039
Mailing Address - Country:US
Mailing Address - Phone:907-451-0389
Mailing Address - Fax:907-451-0210
Practice Address - Street 1:117 SLATER DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3427
Practice Address - Country:US
Practice Address - Phone:907-451-0389
Practice Address - Fax:907-451-0210
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK2528Medicaid