Healthcare Provider Details

I. General information

NPI: 1922874965
Provider Name (Legal Business Name): JANNIC BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 03/01/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 W HATCHER RD STE 101-102
PHOENIX AZ
85021-3173
US

IV. Provider business mailing address

927 W HATCHER RD STE 101-102
PHOENIX AZ
85021-3173
US

V. Phone/Fax

Practice location:
  • Phone: 925-249-8410
  • Fax: 602-699-4689
Mailing address:
  • Phone: 925-249-8410
  • Fax: 602-699-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JONN DMARTIN
Title or Position: CEO
Credential:
Phone: 925-249-8410