Provider Demographics
NPI:1801318134
Name:CROCKER, JAMIE ERIN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ERIN
Last Name:CROCKER
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 1:434 N DENALI ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6011
Mailing Address - Country:US
Mailing Address - Phone:907-841-3772
Mailing Address - Fax:
Practice Address - Street 1:1901 N HEMMER RD
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9690
Practice Address - Country:US
Practice Address - Phone:907-746-7842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101727225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty