Healthcare Provider Details

I. General information

NPI: 1235829201
Provider Name (Legal Business Name): MICHAEL JANSON BASS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 N 95TH AVE STE 132
PHOENIX AZ
85037-4445
US

IV. Provider business mailing address

2700 N CENTRAL AVE STE 1050
PHOENIX AZ
85004-1217
US

V. Phone/Fax

Practice location:
  • Phone: 623-932-6950
  • Fax:
Mailing address:
  • Phone: 602-376-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number291618
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN181884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: