=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538134721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARROD D ROUSSEL PA.-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2006
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9700 N 91ST ST STE A115
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-5036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-803-3370
-----------------------------------------------------
Fax | 415-779-8032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 487 MEADOW LAKE DR
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32439-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-400-4245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9110302
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0110-010484
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085.010957
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10629
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------