Healthcare Provider Details

I. General information

NPI: 1699340638
Provider Name (Legal Business Name): JOHN PAUL CROCKETT LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13421 N 43RD AVE APT 2110
PHOENIX AZ
85029-1038
US

IV. Provider business mailing address

13421 N 43RD AVE APT 2110
PHOENIX AZ
85029-1038
US

V. Phone/Fax

Practice location:
  • Phone: 602-810-8466
  • Fax:
Mailing address:
  • Phone: 480-531-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-24802
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: