Healthcare Provider Details

I. General information

NPI: 1386188720
Provider Name (Legal Business Name): MATTHEW JESELNIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2016
Last Update Date: 12/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 5TH AVE
FAIRBANKS AK
99701-4211
US

IV. Provider business mailing address

1233 5TH AVE
FAIRBANKS AK
99701-4211
US

V. Phone/Fax

Practice location:
  • Phone: 907-317-1093
  • Fax:
Mailing address:
  • Phone: 907-317-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number101139
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: