Provider Demographics
NPI:1699100511
Name:JACKSON, HOLLI VERN (MSW)
Entity type:Individual
Prefix:MR
First Name:HOLLI
Middle Name:VERN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-546-6100
Mailing Address - Fax:907-543-6159
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6100
Practice Address - Fax:907-543-6159
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274031041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid