Healthcare Provider Details

I. General information

NPI: 1336477488
Provider Name (Legal Business Name): JESSICA ENG AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 10/06/2023
Certification Date: 10/05/2023
Deactivation Date: 09/24/2023
Reactivation Date: 10/03/2023

III. Provider practice location address

1832 EAST CYPRESS STREET
PHOENIX AZ
85006
US

IV. Provider business mailing address

1832 EAST CYPRESS STREET
PHOENIX AZ
85006
US

V. Phone/Fax

Practice location:
  • Phone: 480-225-7229
  • Fax:
Mailing address:
  • Phone: 480-225-7229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number297603
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP044342
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: