MEDICARE: MS. JACKIE SUE WOLFE CRT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	227800000X	Certified Respiratory Therapist	6346	AZ
2	2278P1005X	Pulmonary Rehabilitation Certified Respiratory Therapist	6346	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6346	OTHER	AZ	AZ STATE BOARD OF RESPIRATORY CARE EXAMINERS

General Provider Information

NPI Number	:	1023276813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACKIE SUE WOLFE CRT

Provider Business Mailing Address
First Line	:	15640 N 7TH ST
Second Line	:	SUITE 6
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3512
Country	:	US
Telephone Number	:	602-439-3800
Fax Number	:	602-439-3802

Provider Business Practice Location Address
First Line	:	15640 N 7TH ST
Second Line	:	SUITE 6
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3512
Country	:	US
Telephone Number	:	602-439-3800
Fax Number	:	602-439-3802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	05/28/2008

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