Provider Demographics
NPI:1972061059
Name:COLBERT, JESSICA JANELLE (CDC 1)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANELLE
Last Name:COLBERT
Suffix:
Gender:F
Credentials:CDC 1
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 1050
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686-1050
Mailing Address - Country:US
Mailing Address - Phone:907-835-2838
Mailing Address - Fax:907-835-5927
Practice Address - Street 1:911 MEALS AVE
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686
Practice Address - Country:US
Practice Address - Phone:907-835-2838
Practice Address - Fax:907-835-5927
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)