MEDICARE: JESSICA ANGELICA MEDINA

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	385HR2055X	Child Mental Illness Respite Care	8797	AZ

General Provider Information

NPI Number	:	1699833350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANGELICA MEDINA

Provider Business Mailing Address
First Line	:	5540 W IOWA ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-9353
Country	:	US
Telephone Number	:	520-578-9026
Fax Number	:

Provider Business Practice Location Address
First Line	:	5540 W IOWA ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-9353
Country	:	US
Telephone Number	:	520-578-9026
Fax Number	:

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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Directions to “ JESSICA ANGELICA MEDINA ” Practice Location

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