Basic Information
| Provider Information | |||||||||
| NPI: | 1275656654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONDE | ||||||||
| FirstName: | JACKIE | ||||||||
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| Credential: | RRT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 MEDFRA ST | ||||||||
| Address2: | #500 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995015520 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 W INTL AIRPORT RD | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995181107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075656100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
ID Information
| ID | Type | State | Issuer | Description | RT1148 | 05 | AK | MEDICAID | 42328 | 01 | NBRC REGISTRY # | OTHER |