Healthcare Provider Details

I. General information

NPI: 1396345104
Provider Name (Legal Business Name): PATRICIA JEAN PRETORIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEAN PRETORIUS BHP CDC-I

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ELDERBERRY STREET
OLD HARBOR AK
99643
US

IV. Provider business mailing address

PO BOX 72
OLD HARBOR AK
99643-0072
US

V. Phone/Fax

Practice location:
  • Phone: 907-286-2258
  • Fax:
Mailing address:
  • Phone: 907-486-1384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: