Healthcare Provider Details

I. General information

NPI: 1649426826
Provider Name (Legal Business Name): JENNIFER AUSTIN SLACK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4032 N MILLER RD SUITE 108
SCOTTSDALE AZ
85251-4572
US

IV. Provider business mailing address

14780 W MOUNTAIN VIEW BLVD STE 110
SURPRISE AZ
85374-7280
US

V. Phone/Fax

Practice location:
  • Phone: 480-360-2299
  • Fax:
Mailing address:
  • Phone: 623-322-6923
  • Fax: 855-420-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN001303
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberAP3104
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: