Provider Demographics
NPI:1902531825
Name:MARISCAL, JENNIFER C
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:MARISCAL
Suffix:
Gender:F
Credentials:
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 770306
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0306
Mailing Address - Country:US
Mailing Address - Phone:907-529-7005
Mailing Address - Fax:
Practice Address - Street 1:11812 FALKLANDS LOOP
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7320
Practice Address - Country:US
Practice Address - Phone:907-529-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-24
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AK216409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health