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General NPI Number Information
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NPI Number | 1043349400
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Entity Type | Individual
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Provider Name | JESSICA MAE MOODY PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 03/03/2007
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Last Update Date | 03/31/2023
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Provider Practice Location Address
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Address Line | 11201 N TATUM BLVD STE 300
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City | PHOENIX
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State | AZ
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Zip | 85028-6039
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Country | US
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Telephone | 480-900-3556
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Fax |
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Provider Business Mailing Address
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Address Line | 28727 N 20TH AVE
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City | PHOENIX
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State | AZ
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Zip | 85085-0727
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Country | US
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Telephone | 520-780-0129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3474
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 3474
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License Number State | AZ
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