Provider Demographics
NPI:1972955532
Name:GERRISH, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GERRISH
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 1:401 S WASILLA ST UNIT 26
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8173
Mailing Address - Country:US
Mailing Address - Phone:907-982-5039
Mailing Address - Fax:
Practice Address - Street 1:401 S WASILLA ST UNIT 26
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8173
Practice Address - Country:US
Practice Address - Phone:907-982-5039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111149164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse