Healthcare Provider Details

I. General information

NPI: 1174863112
Provider Name (Legal Business Name): JENNA BROOKE PREWITT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA BROOKE KAITZ PA-C

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S COUNTRY CLUB DR STE 101
MESA AZ
85210-6044
US

IV. Provider business mailing address

8408 E SAGE DR
SCOTTSDALE AZ
85250-6740
US

V. Phone/Fax

Practice location:
  • Phone: 480-827-5500
  • Fax:
Mailing address:
  • Phone: 480-827-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5351
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5351
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: