Healthcare Provider Details

I. General information

NPI: 1881559391
Provider Name (Legal Business Name): JENESSA TYLOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S EXTENSION RD
MESA AZ
85210-3420
US

IV. Provider business mailing address

1025 N COUNTRY CLUB DR
MESA AZ
85201-3302
US

V. Phone/Fax

Practice location:
  • Phone: 480-472-1201
  • Fax:
Mailing address:
  • Phone: 480-472-0562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number264161
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: