Healthcare Provider Details

I. General information

NPI: 1700373107
Provider Name (Legal Business Name): JACQLEEN JAANA STETSON AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15333 N PIMA RD STE 305
SCOTTSDALE AZ
85260-2717
US

IV. Provider business mailing address

1170 E TYSON ST
CHANDLER AZ
85225-5498
US

V. Phone/Fax

Practice location:
  • Phone: 669-490-1088
  • Fax:
Mailing address:
  • Phone: 928-595-1568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberAP11203
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP11203
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP11203
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP11203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: