Healthcare Provider Details

I. General information

NPI: 1235687153
Provider Name (Legal Business Name): JENNY BLYTHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 S BRICE
MESA AZ
85212-4183
US

IV. Provider business mailing address

4121 S BRICE
MESA AZ
85212-4183
US

V. Phone/Fax

Practice location:
  • Phone: 480-694-3542
  • Fax:
Mailing address:
  • Phone: 480-694-3542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6083377
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: