Healthcare Provider Details

I. General information

NPI: 1285104372
Provider Name (Legal Business Name): JESSICA ANNE GENNARO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 N 75TH AVE
PHOENIX AZ
85035-1216
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 800-233-3264
  • Fax:
Mailing address:
  • Phone: 602-328-8400
  • Fax: 238-771-0916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17290
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17290
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: