Healthcare Provider Details

I. General information

NPI: 1598077372
Provider Name (Legal Business Name): JESSICA REGNAERT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2927 N 7TH AVE ST. JOSEPH'S FAMILY MEDICINE CENTER
PHOENIX AZ
85013-4102
US

IV. Provider business mailing address

1917 SOUTH CRISMON ROAD
MESA AZ
85208
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3153
  • Fax: 602-406-7176
Mailing address:
  • Phone: 480-610-7100
  • Fax: 480-610-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR71959
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: