Provider Demographics
NPI:1699387746
Name:JENNINGS, ALISHA MARIE
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:MARIE
Last Name:JENNINGS
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 1:615 E 82ND AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-3159
Mailing Address - Country:US
Mailing Address - Phone:907-865-8455
Mailing Address - Fax:913-246-4901
Practice Address - Street 1:615 E 82ND AVE STE 204
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-3159
Practice Address - Country:US
Practice Address - Phone:907-865-8455
Practice Address - Fax:913-246-4901
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK186268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program