Provider Demographics
NPI:1356150304
Name:HAMED, JALAL GAZI
Entity type:Individual
Prefix:
First Name:JALAL
Middle Name:GAZI
Last Name:HAMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 LAKE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-6901
Mailing Address - Country:US
Mailing Address - Phone:727-667-2665
Mailing Address - Fax:
Practice Address - Street 1:12812 OLD GLENN HWY STE A8
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7003
Practice Address - Country:US
Practice Address - Phone:727-667-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-04
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK233645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist