MEDICARE: JASMINE RATTANAVONG MSW

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	104100000X	Social Worker		AK

General Provider Information

NPI Number	:	1699510990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE RATTANAVONG MSW

Provider Business Mailing Address
First Line	:	PO BOX 31001
Second Line	:	4166
City	:	PASADENA
State	:	CA
Zip	:	91110-4166
Country	:	US
Telephone Number	:	866-747-2455
Fax Number	:

Provider Business Practice Location Address
First Line	:	3331 LAKE OTIS PKWY
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4565
Country	:	US
Telephone Number	:	907-290-2126
Fax Number	:

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

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	03/10/2026

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