Healthcare Provider Details

I. General information

NPI: 1740271741
Provider Name (Legal Business Name): JACQUELINE ELIZABETH CHASE R. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 KANAKANAK ROAD
DILLINGHAM AK
99576-0130
US

IV. Provider business mailing address

PO BOX 130
DILLINGHAM AK
99576-0130
US

V. Phone/Fax

Practice location:
  • Phone: 907-842-9276
  • Fax: 907-842-9281
Mailing address:
  • Phone: 907-842-9276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number153
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: