Healthcare Provider Details

I. General information

NPI: 1447874755
Provider Name (Legal Business Name): JENNA DERUBEIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 111
PHOENIX AZ
85048-0559
US

IV. Provider business mailing address

3911 W BUIST AVE
LAVEEN AZ
85339-1251
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-2020
  • Fax:
Mailing address:
  • Phone: 480-330-1162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002424
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT-002424
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT-002424
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: