Healthcare Provider Details

I. General information

NPI: 1780274548
Provider Name (Legal Business Name): CARSON JAY YACH MASTER OF EDUCATION
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LYNCH STREET
WRANGELL AK
99929-1231
US

IV. Provider business mailing address

PO BOX 1231
WRANGELL AK
99929-1231
US

V. Phone/Fax

Practice location:
  • Phone: 907-874-5008
  • Fax:
Mailing address:
  • Phone: 907-874-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: