=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942333760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHIATRIC ASSOCIATES OF NORTHERN AZ PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 05/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 SOUTH MCCORMICK SUITE #200
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-8400
-----------------------------------------------------
Fax | 928-776-0208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 SOUTH MCCORMICK SUITE #200
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-8400
-----------------------------------------------------
Fax | 928-776-0208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | JEFFREY FREEMAN PENNEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 928-445-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------