Healthcare Provider Details

I. General information

NPI: 1992514145
Provider Name (Legal Business Name): ADRA JAEHNIG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9620 N METRO PKWY W STE 143
PHOENIX AZ
85051-1441
US

IV. Provider business mailing address

20325 N. 51ST AVE. BLDG 8 STE. 160
GLENDALE AZ
85308-4622
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-4905
  • Fax:
Mailing address:
  • Phone: 623-466-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226306
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: