Provider Demographics
NPI:1104455450
Name:JACKSON, REBECA LEE
Entity type:Individual
Prefix:MISS
First Name:REBECA
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AYME
Other - Middle Name:ISEL
Other - Last Name:MARRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7451 TYONE CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3531
Mailing Address - Country:US
Mailing Address - Phone:907-743-2986
Mailing Address - Fax:907-743-2986
Practice Address - Street 1:7451 TYONE CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3531
Practice Address - Country:US
Practice Address - Phone:907-743-2986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101381310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility