Healthcare Provider Details

I. General information

NPI: 1992500060
Provider Name (Legal Business Name): JORDAN GABBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 W ASPERA BLVD STE 301
GLENDALE AZ
85308-7947
US

IV. Provider business mailing address

7701 W ASPERA BLVD STE 301
GLENDALE AZ
85308-7947
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-2109
  • Fax:
Mailing address:
  • Phone: 623-248-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number253092
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: