Healthcare Provider Details

I. General information

NPI: 1003679846
Provider Name (Legal Business Name): JENASEE LORETTA SOUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST STE 620
PHOENIX AZ
85006-2850
US

IV. Provider business mailing address

1300 N 12TH ST STE 620
PHOENIX AZ
85006-2850
US

V. Phone/Fax

Practice location:
  • Phone: 602-283-3668
  • Fax: 833-471-4382
Mailing address:
  • Phone: 602-283-3668
  • Fax: 833-471-4382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number308886
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: