Healthcare Provider Details

I. General information

NPI: 1588488993
Provider Name (Legal Business Name): CORINA WRIGHT-JACK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 W APACHE TRL STE 101
APACHE JUNCTION AZ
85120-3733
US

IV. Provider business mailing address

3607 N 106TH DR
AVONDALE AZ
85392-4465
US

V. Phone/Fax

Practice location:
  • Phone: 480-999-3323
  • Fax: 480-999-3324
Mailing address:
  • Phone: 480-450-2362
  • Fax: 480-999-3324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23335
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: