Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003285651 |
---|---|
Provider Name | Jonathan Liberty |
First Address | Bethel, AK 99559-0528 |
Second Address | Bethel, AK 99559 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2015 |
Last Update Date | 24/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1020986 | (05) | AK |