Healthcare Provider Details

I. General information

NPI: 1124799556
Provider Name (Legal Business Name): JENNIFER M NEWMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 E REZANOF DR
KODIAK AK
99615-6416
US

IV. Provider business mailing address

PO BOX 3290
PORTLAND OR
97208-3290
US

V. Phone/Fax

Practice location:
  • Phone: 907-481-2400
  • Fax: 907-481-2419
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: