MEDICARE: DR. JENNIFER CHAFFIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	2004016368	MO
2	2084P0800X	Psychiatry Physician	A103656	CA
3	2084P0800X	Psychiatry Physician	60051	AZ

General Provider Information

NPI Number	:	1639370018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER CHAFFIN M.D.

Provider Business Mailing Address
First Line	:	9741 E TELEMETRY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-8510
Country	:	US
Telephone Number	:	314-882-8123
Fax Number	:	480-988-0102

Provider Business Practice Location Address
First Line	:	1525 S HIGLEY RD # 104-161
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4795
Country	:	US
Telephone Number	:	314-882-8123
Fax Number	:	480-988-0102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	11/30/2022

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