Healthcare Provider Details

I. General information

NPI: 1396315438
Provider Name (Legal Business Name): JENNIFER JULIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 W AGUA FRIA FWY STE 1090
PHOENIX AZ
85027-3970
US

IV. Provider business mailing address

PO BOX 80217
PHOENIX AZ
85060-0217
US

V. Phone/Fax

Practice location:
  • Phone: 602-648-5444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8543
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8543
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: