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General NPI Number Information
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NPI Number | 1649642786
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Entity Type | Organization
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Legal Business Name | NATIVE VLLAGE OF EKLUTNA
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Dates
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Enumeration Date | 10/28/2015
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Last Update Date | 10/28/2015
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Provider Practice Location Address
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Address Line | 26339 EKLUTNA VILLAGE RD
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City | CHUGIAK
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State | AK
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Zip | 99567-5148
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Country | US
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Telephone | 907-688-6031
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Fax | 907-688-6032
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Provider Business Mailing Address
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Address Line | 26339 EKLUTNA VILLAGE RD
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City | CHUGIAK
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State | AK
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Zip | 99567-5148
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Country | US
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Telephone | 907-688-6031
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Fax | 907-688-6032
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Authorized Official
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Title or Position | SOCIAL SERVICE DIRECTOR
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Name | JAMISON MARIE COLE
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Credential | MSW LCSW
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Telephone | 907688601808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 1025602
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License Number State | AK
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