Healthcare Provider Details

I. General information

NPI: 1134413180
Provider Name (Legal Business Name): JAKE B BARNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 E BROADWAY RD
TEMPE AZ
85282-1614
US

IV. Provider business mailing address

1840 E BROADWAY RD
TEMPE AZ
85282-1614
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax: 480-927-1092
Mailing address:
  • Phone: 602-243-7277
  • Fax: 480-927-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number007157
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: