Healthcare Provider Details

I. General information

NPI: 1033407796
Provider Name (Legal Business Name): JENEE POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W TALAVI BLVD SUITE 180
GLENDALE AZ
85306-1886
US

IV. Provider business mailing address

4747 N 7TH ST SUITE 100
PHOENIX AZ
85014-3653
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-8202
  • Fax:
Mailing address:
  • Phone: 602-279-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: