Healthcare Provider Details

I. General information

NPI: 1023724085
Provider Name (Legal Business Name): JAZZ TAYLOR WHITE MOTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13385 W MCDOWELL RD
GOODYEAR AZ
85395-2631
US

IV. Provider business mailing address

4222 S 186TH AVE
GOODYEAR AZ
85338-7974
US

V. Phone/Fax

Practice location:
  • Phone: 623-986-5110
  • Fax:
Mailing address:
  • Phone: 801-649-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number009039
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: