Healthcare Provider Details

I. General information

NPI: 1649505181
Provider Name (Legal Business Name): JESSICA RAE HEPBURN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. JESSICA RAE HUTH

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9321 W THOMAS RD STE 205
PHOENIX AZ
85037-3392
US

IV. Provider business mailing address

18444 N 25TH AVE SUITE 310
PHOENIX AZ
85023-1261
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 623-537-5600
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4466
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4466
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4466
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: