Provider Demographics
NPI:1821206376
Name:JACKS, MARY STARK (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:STARK
Last Name:JACKS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232245
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-2245
Mailing Address - Country:US
Mailing Address - Phone:907-868-3562
Mailing Address - Fax:907-868-3562
Practice Address - Street 1:2340 SENTRY DR APT 805
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-5344
Practice Address - Country:US
Practice Address - Phone:907-344-8869
Practice Address - Fax:907-868-3562
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK902213171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator