Provider Demographics
NPI:1477951192
Name:SCURLOCK, JACQUELINE OMENITSCH (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:OMENITSCH
Last Name:SCURLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:E
Other - Last Name:OMENITSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2949
Mailing Address - Country:US
Mailing Address - Phone:240-674-3191
Mailing Address - Fax:
Practice Address - Street 1:230 E MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-262-3119
Practice Address - Fax:907-262-9290
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18453101YM0800X
AK1475571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health