Healthcare Provider Details

I. General information

NPI: 1679380950
Provider Name (Legal Business Name): JAALA ANN WICKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 UPLAND ST
KENAI AK
99611-8026
US

IV. Provider business mailing address

PO BOX 988
KENAI AK
99611-0988
US

V. Phone/Fax

Practice location:
  • Phone: 907-335-7500
  • Fax:
Mailing address:
  • Phone: 907-335-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: