Healthcare Provider Details

I. General information

NPI: 1528807187
Provider Name (Legal Business Name): MELINDA JAGGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 W. LOWELL DR
SAN TAN VALLEY AZ
85140
US

IV. Provider business mailing address

1034 W. LOWELL DR
SAN TAN VALLEY AZ
85140
US

V. Phone/Fax

Practice location:
  • Phone: 480-278-5558
  • Fax:
Mailing address:
  • Phone: 480-278-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number307475
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number307475
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: