Healthcare Provider Details

I. General information

NPI: 1619847175
Provider Name (Legal Business Name): JESSICA ANNE WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 E CAMELBACK RD STE 400
PHOENIX AZ
85016-3514
US

IV. Provider business mailing address

2325 E CAMELBACK RD STE 400
PHOENIX AZ
85016-3514
US

V. Phone/Fax

Practice location:
  • Phone: 602-782-5222
  • Fax: 480-900-8714
Mailing address:
  • Phone: 602-782-5222
  • Fax: 480-900-8714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: