1356383723 NPI number — DR. TINA J JESSEE AU.D.

Table of content: DR. TINA J JESSEE AU.D. (NPI 1356383723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356383723 NPI number — DR. TINA J JESSEE AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESSEE
Provider First Name:
TINA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
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:
1356383723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W GUADALUPE RD
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85233-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-497-0780
Provider Business Mailing Address Fax Number:
480-497-0790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 W GUADALUPE RD
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85233-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-497-0780
Provider Business Practice Location Address Fax Number:
480-497-0790
Provider Enumeration Date:
06/12/2006

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: 237600000X , with the licence number:  DA0060 , 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: DA0060 . This is a "STATE LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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