Provider Demographics
NPI:1568523157
Name:JACKSON, BENNETT J (ANP)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 DEBARR RD STE C
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1783
Mailing Address - Country:US
Mailing Address - Phone:907-333-7425
Mailing Address - Fax:907-333-7719
Practice Address - Street 1:6307 DEBARR RD STE C
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1783
Practice Address - Country:US
Practice Address - Phone:907-333-7425
Practice Address - Fax:907-333-7719
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1730113739OtherGROUP NPI
AKNP39831Medicaid
AKK153074Medicare ID - Type UnspecifiedAK MEDICARE
AKNP39831Medicaid