Healthcare Provider Details

I. General information

NPI: 1598585325
Provider Name (Legal Business Name): JENNIFER MACHACEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12812 OLD GLENN HWY STE A8
EAGLE RIVER AK
99577-7003
US

IV. Provider business mailing address

525 S DAYSHA CIR
PALMER AK
99645-8421
US

V. Phone/Fax

Practice location:
  • Phone: 907-696-8020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number229792
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: