Provider Demographics
NPI:1497407407
Name:RUST, JAMISON
Entity Type:Individual
Prefix:
First Name:JAMISON
Middle Name:
Last Name:RUST
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 1:3210 DENALI ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-4041
Mailing Address - Country:US
Mailing Address - Phone:907-677-6953
Mailing Address - Fax:
Practice Address - Street 1:3210 DENALI ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-4041
Practice Address - Country:US
Practice Address - Phone:907-677-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK181426225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist