Provider Demographics
NPI:1629323910
Name:ERIBAL, JENNIE DALAODAO
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:DALAODAO
Last Name:ERIBAL
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 1:3505 E 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3368
Mailing Address - Country:US
Mailing Address - Phone:907-717-6640
Mailing Address - Fax:
Practice Address - Street 1:3505 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3368
Practice Address - Country:US
Practice Address - Phone:907-717-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100929320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities