Healthcare Provider Details

I. General information

NPI: 1073947115
Provider Name (Legal Business Name): JASON ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W UTOPIA RD STE 100
PHOENIX AZ
85027-4172
US

IV. Provider business mailing address

2500 W UTOPIA RD STE 100
PHOENIX AZ
85027-4172
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-4820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64164
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: