Healthcare Provider Details

I. General information

NPI: 1902298748
Provider Name (Legal Business Name): JESSICA LANE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 N SWAN RD
TUCSON AZ
85712-1259
US

IV. Provider business mailing address

3085 N SWAN RD
TUCSON AZ
85712-1259
US

V. Phone/Fax

Practice location:
  • Phone: 520-323-3099
  • Fax: 520-323-3460
Mailing address:
  • Phone: 520-323-3099
  • Fax: 520-323-3460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61160
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: