Healthcare Provider Details

I. General information

NPI: 1750735163
Provider Name (Legal Business Name): JACKIE OLLIS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N PLAZA DR
APACHE JUNCTION AZ
85120-5501
US

IV. Provider business mailing address

1351 N ALMA SCHOOL RD
CHANDLER AZ
85224-5936
US

V. Phone/Fax

Practice location:
  • Phone: 480-474-5584
  • Fax:
Mailing address:
  • Phone: 480-814-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP8521
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN197907
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: