1811468804 NPI number — SUMMIT HEALTHCARE ASSOCIATION

Table of content: MRS. SHAWNNA RAE JANTZ M.A. LPCC (NPI 1093430522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811468804 NPI number — SUMMIT HEALTHCARE ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT HEALTHCARE ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1811468804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 E. SHOW LOW LAKE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHOW LOW
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-537-6321
Provider Business Mailing Address Fax Number:
928-537-7814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4951 SOUTH WHITE MOUNTAIN ROAD, BLDG A., SUITE 1500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOW LOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-537-6336
Provider Business Practice Location Address Fax Number:
928-532-3506
Provider Enumeration Date:
12/17/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CHIEF NURSING OFFICER
Authorized Official Telephone Number:
928-537-6932

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 470811 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".