Healthcare Provider Details

I. General information

NPI: 1639049620
Provider Name (Legal Business Name): JENNELLE STAUB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 E THOMAS RD STE 100
PHOENIX AZ
85016-8220
US

IV. Provider business mailing address

3450 N 3RD ST
PHOENIX AZ
85012-2331
US

V. Phone/Fax

Practice location:
  • Phone: 602-957-2507
  • Fax:
Mailing address:
  • Phone: 602-265-8338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: