Provider Demographics
NPI:1932170297
Name:FORTSON, JAYNE S (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:S
Last Name:FORTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2401 E 42ND AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5205
Mailing Address - Country:US
Mailing Address - Phone:907-563-3204
Mailing Address - Fax:907-563-4283
Practice Address - Street 1:2401 E 42ND AVE
Practice Address - Street 2:STE 301
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5205
Practice Address - Country:US
Practice Address - Phone:907-563-3204
Practice Address - Fax:907-563-4283
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK2600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2600Medicaid
AKE77986Medicare UPIN
AK150347Medicare ID - Type Unspecified