1427296490 NPI number — JESSICA DANIELS MD

Table of content: JESSICA DANIELS MD (NPI 1427296490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427296490 NPI number — JESSICA DANIELS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIELS
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427296490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 42210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85080-2210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-266-7770
Provider Business Mailing Address Fax Number:
623-322-4639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-406-3402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  R70164 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 708206 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".