Provider Demographics
NPI:1598244303
Name:JACKSON, ASISALYN W
Entity Type:Individual
Prefix:
First Name:ASISALYN
Middle Name:W
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 1:101 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:AKIACHAK
Mailing Address - State:AK
Mailing Address - Zip Code:99551
Mailing Address - Country:US
Mailing Address - Phone:907-825-4011
Mailing Address - Fax:907-825-4173
Practice Address - Street 1:101 MAIN STREET
Practice Address - Street 2:
Practice Address - City:AKIACHAK
Practice Address - State:AK
Practice Address - Zip Code:99551
Practice Address - Country:US
Practice Address - Phone:907-825-4011
Practice Address - Fax:907-825-4173
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker