Healthcare Provider Details

I. General information

NPI: 1043909229
Provider Name (Legal Business Name): DEREK JEANES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

IV. Provider business mailing address

63 S ROCKFORD DR STE 220
TEMPE AZ
85288-6226
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-1234
  • Fax: 602-508-4830
Mailing address:
  • Phone: 928-445-1324
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002719
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: