Healthcare Provider Details

I. General information

NPI: 1497888572
Provider Name (Legal Business Name): VANESSA RACHEL JACKSON CDM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 GAFFNEY RD SUITE 100
FAIRBANKS AK
99701-4610
US

IV. Provider business mailing address

728 GAFFNEY RD SUITE 100
FAIRBANKS AK
99701-4610
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-3719
  • Fax: 907-456-1511
Mailing address:
  • Phone: 907-456-3719
  • Fax: 907-456-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAA42
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: