Healthcare Provider Details

I. General information

NPI: 1295818607
Provider Name (Legal Business Name): JESSICA AUDRYLEE WHITAKER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD BLDG 317 56MOS/SGOHF - LUKE AIR FORCE BASE
GLENDALE AZ
85309-1529
US

IV. Provider business mailing address

5901 W BEHREND DR APT 2134
GLENDALE AZ
85308-6954
US

V. Phone/Fax

Practice location:
  • Phone: 877-557-3422
  • Fax: 877-875-2500
Mailing address:
  • Phone: 623-877-0599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW10272
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: