Provider Demographics
NPI:1760848261
Name:ENINGOWUK, JACKIE (CHA-T)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ENINGOWUK
Suffix:
Gender:F
Credentials:CHA-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 OCEANVIEW
Mailing Address - Street 2:
Mailing Address - City:SHISHMAREF
Mailing Address - State:AK
Mailing Address - Zip Code:99772
Mailing Address - Country:US
Mailing Address - Phone:907-649-3311
Mailing Address - Fax:907-649-2083
Practice Address - Street 1:123 OCEANVIEW
Practice Address - Street 2:
Practice Address - City:SHISHMAREF
Practice Address - State:AK
Practice Address - Zip Code:99772
Practice Address - Country:US
Practice Address - Phone:907-649-3311
Practice Address - Fax:907-649-2083
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-TOtherCHA-T