=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306823810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER J BORTZ PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2005
-----------------------------------------------------
Last Update Date | 12/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2929 E CAMELBACK RD STE 114
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-795-4787
-----------------------------------------------------
Fax | 480-795-7778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34522 N SCOTTSDALE RD STE 120-227
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85266-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-795-4787
-----------------------------------------------------
Fax | 480-795-7778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2060
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 2060
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------