Healthcare Provider Details

I. General information

NPI: 1386192177
Provider Name (Legal Business Name): JENNIFER K CARLSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER K ANDERSEN PHD

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 S VAL VISTA DR BLDG 4
GILBERT AZ
85295-1675
US

IV. Provider business mailing address

1920 BRIARCLIFF RD NE
ATLANTA GA
30329-4010
US

V. Phone/Fax

Practice location:
  • Phone: 480-608-4640
  • Fax:
Mailing address:
  • Phone: 404-785-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009836
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005907
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-005907
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.009836
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY.0006727
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: