Provider Demographics
NPI:1477858132
Name:RAMOS, JACQUELINE DENNISE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENNISE
Last Name:RAMOS
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 1:107 MATTHEW PAUL WAY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4888
Mailing Address - Country:US
Mailing Address - Phone:907-310-6434
Mailing Address - Fax:907-337-2337
Practice Address - Street 1:107 MATTHEW PAUL WAY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4888
Practice Address - Country:US
Practice Address - Phone:907-310-6434
Practice Address - Fax:907-337-2337
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100909310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1584539Medicaid
AK1636011Medicaid