Provider Demographics
NPI:1992461420
Name:FOOTHILLS BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:FOOTHILLS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:208-360-0288
Mailing Address - Street 1:16635 CENTERFIELD DR STE 204
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7746
Mailing Address - Country:US
Mailing Address - Phone:907-694-2300
Mailing Address - Fax:907-694-2330
Practice Address - Street 1:16635 CENTERFIELD DR STE 204
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7746
Practice Address - Country:US
Practice Address - Phone:907-694-2300
Practice Address - Fax:907-694-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty