Healthcare Provider Details

I. General information

NPI: 1669632709
Provider Name (Legal Business Name): JENNA R PAUL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4145 W PARK ST
PHOENIX AZ
85041-6092
US

IV. Provider business mailing address

4145 W PARK ST
PHOENIX AZ
85041-6092
US

V. Phone/Fax

Practice location:
  • Phone: 808-896-2427
  • Fax:
Mailing address:
  • Phone: 808-896-2427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30859
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: