Provider Demographics
NPI:1114400637
Name:SIMPSON-JACKSON, QUANIKA SHUNTAAYE (MD)
Entity Type:Individual
Prefix:
First Name:QUANIKA
Middle Name:SHUNTAAYE
Last Name:SIMPSON-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 N 19TH AVE STE 300-28
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3210
Mailing Address - Country:US
Mailing Address - Phone:602-698-8261
Mailing Address - Fax:
Practice Address - Street 1:202 E EARLL DR STE 360
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2677
Practice Address - Country:US
Practice Address - Phone:602-698-8261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV51627-AO-0207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV8389PCS0Medicaid