Healthcare Provider Details

I. General information

NPI: 1205086261
Provider Name (Legal Business Name): BETH LOUISE JACO CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH LOUISE JACO CPNP

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 S. VAL VISTA DRIVE SUITE 167, BLD 12
GILBERT AZ
85295
US

IV. Provider business mailing address

2680 S. VAL VISTA DRIVE SUITE 167, BLD 12
GILBERT AZ
85295
US

V. Phone/Fax

Practice location:
  • Phone: 480-857-0222
  • Fax: 480-857-0200
Mailing address:
  • Phone: 480-857-0222
  • Fax: 480-857-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number197
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN073431
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: