Provider Demographics
NPI:1770610925
Name:SONTAG, JAYNE (LAC)
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:SONTAG
Suffix:
Gender:F
Credentials:LAC
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 1373
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1373
Mailing Address - Country:US
Mailing Address - Phone:907-748-5895
Mailing Address - Fax:907-262-6411
Practice Address - Street 1:47010 TOBACCO LANE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-748-5895
Practice Address - Fax:907-262-6411
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK31171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
92-0164143OtherIRS INDIVIDUAL TAXPAYER