Healthcare Provider Details

I. General information

NPI: 1154091932
Provider Name (Legal Business Name): JONATHAN HOWELL RUTHERFORD PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CALLE PORTAL STE 300
SIERRA VISTA AZ
85635-2900
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-3011
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number260129
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: