Healthcare Provider Details

I. General information

NPI: 1164120150
Provider Name (Legal Business Name): CLAY JUSTIN CROCKETT PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 S HIGLEY RD STE 104
GILBERT AZ
85296-5045
US

IV. Provider business mailing address

1525 S HIGLEY RD STE 104
GILBERT AZ
85296-5045
US

V. Phone/Fax

Practice location:
  • Phone: 480-401-2110
  • Fax: 507-519-5792
Mailing address:
  • Phone: 480-401-2110
  • Fax: 507-519-5792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP70013458
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10050854
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN197246
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number294847
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: