Provider Demographics
NPI:1043349400
Name:MOODY, JESSICA MAE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MAE
Last Name:MOODY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28727 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0727
Mailing Address - Country:US
Mailing Address - Phone:520-780-0129
Mailing Address - Fax:
Practice Address - Street 1:11201 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6039
Practice Address - Country:US
Practice Address - Phone:480-900-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3474363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical