Healthcare Provider Details

I. General information

NPI: 1861895682
Provider Name (Legal Business Name): MISTY WILCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
JBER AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-5858
  • Fax:
Mailing address:
  • Phone: 907-580-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number153752
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06973
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: