Healthcare Provider Details

I. General information

NPI: 1639570203
Provider Name (Legal Business Name): J&J INDEPENDENT LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2014
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 E. PARKS HWY SUITE 106
WASILLA AK
99654-3909
US

IV. Provider business mailing address

165 E PARKS HWY SUITE 106
WASILLA AK
99654-7059
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-3953
  • Fax: 907-373-3983
Mailing address:
  • Phone: 907-373-3953
  • Fax: 907-373-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number1002558
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1002558
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1624210
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateAK
# 6
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number1624210
License Number StateAK

VIII. Authorized Official

Name: BILLIE JO HANSEN
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 907-715-6507