Provider Demographics
NPI:1073990149
Name:ERICKSON, JENNA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ROSE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:ROSE
Other - Last Name:MOLLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-933-0777
Practice Address - Fax:602-933-0755
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56104208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics