Healthcare Provider Details

I. General information

NPI: 1972072452
Provider Name (Legal Business Name): JALYN GORMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8607 E PECOS RD STE 116
MESA AZ
85212-6572
US

IV. Provider business mailing address

8607 E PECOS RD STE 116
MESA AZ
85212-6572
US

V. Phone/Fax

Practice location:
  • Phone: 480-500-1446
  • Fax:
Mailing address:
  • Phone: 480-500-1446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-009263
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-034954
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: