Healthcare Provider Details

I. General information

NPI: 1720992811
Provider Name (Legal Business Name): NORTHERN PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 S HERMON RD STE 6
WASILLA AK
99654-7385
US

IV. Provider business mailing address

2521 E MOUNTAIN VILLAGE DR STE B926
WASILLA AK
99654-7373
US

V. Phone/Fax

Practice location:
  • Phone: 907-416-3462
  • Fax:
Mailing address:
  • Phone: 907-952-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSE COOPER
Title or Position: MANAGING MEMBER
Credential: APRN
Phone: 907-952-8944