Healthcare Provider Details

I. General information

NPI: 1215190749
Provider Name (Legal Business Name): JESSICA MICHELE BERDEJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA YBARRA M.D

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9225 N 3RD ST SUITE 103
PHOENIX AZ
85020-2439
US

IV. Provider business mailing address

2500 W UTOPIA RD SUITE 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 602-906-3500
  • Fax: 602-906-3519
Mailing address:
  • Phone: 623-434-6200
  • Fax: 623-434-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA115734
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number46095
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: