Provider Demographics
NPI:1528358512
Name:POLLOS, JACQUELYNN M (BA)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:M
Last Name:POLLOS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:JACQUELYNN
Other - Middle Name:M
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3433 MOOSEWALK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6251
Mailing Address - Country:US
Mailing Address - Phone:907-460-6292
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-455-1416
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AK630534374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No374700000XNursing Service Related ProvidersTechnician