Healthcare Provider Details

I. General information

NPI: 1275895690
Provider Name (Legal Business Name): JESSICA NICOLE ENDRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 W 700 S SUITE D
SPRINGVILLE UT
84663-4963
US

IV. Provider business mailing address

2450 S EL DORADO
MESA AZ
85202-7306
US

V. Phone/Fax

Practice location:
  • Phone: 801-489-9721
  • Fax:
Mailing address:
  • Phone: 602-421-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18437
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: