Active NPI
Holli Vern Jackson, MSW
- Clinical Social Worker
- Bethel, AK
National Provider Identifier
1699100511
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- Practice address
- 829 Chief Eddie Hoffman Hwy
Bethel, AK 99559 - Phone
- (907) 543-6100
- Fax
- (907) 543-6159
- NPI assigned
- Sep 10, 2013
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 27403 | CA | |
| Clinical Social Worker | 1041C0700X | Primary |
Addresses
Primary practice location
829 Chief Eddie Hoffman Hwy
Bethel, AK 99559
Mailing address
PO Box 528
Bethel, AK 99559-0528
Phone (907) 546-6100
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1020986 | Medicaid | AK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 27403 | CA | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1378771200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1574208000000",
"number": "1699100511",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 528",
"city": "BETHEL",
"state": "AK",
"postal_code": "995590528",
"telephone_number": "907-546-6100",
"fax_number": "907-543-6159"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "829 CHIEF EDDIE HOFFMAN HWY",
"city": "BETHEL",
"state": "AK",
"postal_code": "99559",
"telephone_number": "907-543-6100",
"fax_number": "907-543-6159"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "HOLLI",
"middle_name": "VERN",
"name_prefix": "Mr.",
"credential": "MSW",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2013-09-10",
"last_updated": "2019-11-20",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "CA",
"license": "27403",
"primary": false
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1020986",
"state": "AK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bethel, AK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.