Provider Demographics
NPI:1508206772
Name:JACKSON, MARY S
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:JACKSON
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 1:49 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:KWETHLUK
Mailing Address - State:AK
Mailing Address - Zip Code:99621
Mailing Address - Country:US
Mailing Address - Phone:907-757-6627
Mailing Address - Fax:907-757-6626
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-6300
Practice Address - Fax:907-543-6366
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker