MEDICARE: JODY HALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1164723516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODY HALL

Provider Business Mailing Address
First Line	:	PO BOX 299136
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99629-9136
Country	:	US
Telephone Number	:	907-892-6944
Fax Number	:	907-892-6945

Provider Business Practice Location Address
First Line	:	12528 HAWK LANE
Second Line	:
City	:	HOUSTON
State	:	AK
Zip	:	99694
Country	:	US
Telephone Number	:	907-892-6944
Fax Number	:	907-892-6945

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	11/16/2010

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