Healthcare Provider Details

I. General information

NPI: 1164824900
Provider Name (Legal Business Name): JELINA IP ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 S COTTONWOOD DR
TEMPE AZ
85282-3014
US

IV. Provider business mailing address

2050 S COTTONWOOD DR
TEMPE AZ
85282-3014
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-4540
  • Fax:
Mailing address:
  • Phone: 480-704-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNT60601419
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60601419
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: