Healthcare Provider Details

I. General information

NPI: 1679207914
Provider Name (Legal Business Name): JESSICA TA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S DOBSON RD STE 115
CHANDLER AZ
85286-6166
US

IV. Provider business mailing address

601 N 3RD AVE UNIT 1216
PHOENIX AZ
85003-1784
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-2991
  • Fax:
Mailing address:
  • Phone: 954-940-1285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10924
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number10924
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: