Healthcare Provider Details

I. General information

NPI: 1104482124
Provider Name (Legal Business Name): JESSICA MARIE SCHIRTZINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 E MAIN ST
MESA AZ
85203-8906
US

IV. Provider business mailing address

1234 E MAIN ST
MESA AZ
85203-8906
US

V. Phone/Fax

Practice location:
  • Phone: 888-123-4567
  • Fax:
Mailing address:
  • Phone: 888-123-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8006
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: