Healthcare Provider Details

I. General information

NPI: 1750919023
Provider Name (Legal Business Name): JALICIA STURDIVANT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 06/20/2024
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15351 W BELL RD
SURPRISE AZ
85374-4580
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2273
  • Fax: 623-214-5214
Mailing address:
  • Phone: 480-964-2273
  • Fax: 623-974-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number010924
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number95609
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: