Healthcare Provider Details

I. General information

NPI: 1720336910
Provider Name (Legal Business Name): JETTA VALLE MSN, PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/24/2025
Certification Date: 08/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21168 E OCOTILLO RD # 1271
QUEEN CREEK AZ
85142-8175
US

IV. Provider business mailing address

21168 E OCOTILLO RD # 1271
QUEEN CREEK AZ
85142-8175
US

V. Phone/Fax

Practice location:
  • Phone: 520-677-8025
  • Fax: 888-205-9338
Mailing address:
  • Phone: 520-677-8025
  • Fax: 888-205-9338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberAP10652
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10652
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP10652
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP10652
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: