Provider Demographics
NPI:1548407497
Name:STACK, JEANETTE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24712 TEAL LOOP
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-5114
Mailing Address - Country:US
Mailing Address - Phone:907-351-7191
Mailing Address - Fax:907-622-4001
Practice Address - Street 1:984 N MERIDIAN PL STE A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7215
Practice Address - Country:US
Practice Address - Phone:907-631-4029
Practice Address - Fax:907-631-4128
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00014238225700000X
AK101955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist