Healthcare Provider Details

I. General information

NPI: 1679067052
Provider Name (Legal Business Name): JORDEN RAE HART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W FIRESTORM WAY
GLENDALE AZ
85306-3216
US

IV. Provider business mailing address

21150 N TATUM BLVD APT 3037
PHOENIX AZ
85050-7237
US

V. Phone/Fax

Practice location:
  • Phone: 602-489-5300
  • Fax:
Mailing address:
  • Phone: 480-204-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-009247
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: