Healthcare Provider Details

I. General information

NPI: 1952677866
Provider Name (Legal Business Name): AMY L JENCKS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9003 E SHEA BLVD
SCOTTSDALE AZ
85260-6709
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO MSC PATHOLOGY
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 480-323-3383
  • Fax:
Mailing address:
  • Phone: 505-938-8456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA-2034-17
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number007981
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: