Healthcare Provider Details

I. General information

NPI: 1730930637
Provider Name (Legal Business Name): JESSICA LANE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W ORANGE GROVE RD STE 302
TUCSON AZ
85704-1152
US

IV. Provider business mailing address

1925 W ORANGE GROVE RD STE 302
TUCSON AZ
85704-1152
US

V. Phone/Fax

Practice location:
  • Phone: 520-797-3888
  • Fax:
Mailing address:
  • Phone: 520-797-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA LANE
Title or Position: PEDIATRICIAN
Credential:
Phone: 520-797-3888