Healthcare Provider Details

I. General information

NPI: 1295571198
Provider Name (Legal Business Name): JACOB MALOUF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE MALOUF RN

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 DENALI ST STE 102
ANCHORAGE AK
99503-4099
US

IV. Provider business mailing address

9430 BIRCH RD
ANCHORAGE AK
99507-6628
US

V. Phone/Fax

Practice location:
  • Phone: 907-360-4275
  • Fax:
Mailing address:
  • Phone: 907-360-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number24505
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number24505
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: