MEDICARE: JENNA YVONNE JUDD PTA

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	225200000X	Physical Therapy Assistant	014413	AZ

General Provider Information

NPI Number	:	1881355717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA YVONNE JUDD PTA

Provider Business Mailing Address
First Line	:	921 W UNIVERSITY DR UNIT 1181
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-5554
Country	:	US
Telephone Number	:	928-965-0113
Fax Number	:

Provider Business Practice Location Address
First Line	:	12545 N SAGUARO BLVD
Second Line	:
City	:	FOUNTAIN HILLS
State	:	AZ
Zip	:	85268-3857
Country	:	US
Telephone Number	:	480-837-1530
Fax Number	:

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

Provider Enumeration Date	:	01/03/2022
Last Update Date	:	01/03/2022

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