Provider Demographics
NPI:1538230701
Name:JADE ACUPUNCTURE AND BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:JADE ACUPUNCTURE AND BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:COURTNAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DAC, PSYD
Authorized Official - Phone:907-243-3031
Mailing Address - Street 1:626 K ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3329
Mailing Address - Country:US
Mailing Address - Phone:907-243-3031
Mailing Address - Fax:907-243-3922
Practice Address - Street 1:626 K ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3329
Practice Address - Country:US
Practice Address - Phone:907-243-3031
Practice Address - Fax:907-243-3922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK401103TC0700X
AK003171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160313Medicare ID - Type Unspecified