Healthcare Provider Details

I. General information

NPI: 1881058238
Provider Name (Legal Business Name): DEEPTHY JOLAL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 W CACTUS RD
PHOENIX AZ
85029-2924
US

IV. Provider business mailing address

5542 W CAVEDALE DR
PHOENIX AZ
85083-6369
US

V. Phone/Fax

Practice location:
  • Phone: 602-547-5919
  • Fax:
Mailing address:
  • Phone: 623-337-1146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8609
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: